Vibration training improves balance in unstable ankles

Functional ankle instability (FAI) is a common condition following ankle injury characterised by increased risk of injury. Ankle sprains are a common acute form of injury suffered in dancing and loss of balance can affect not only risk of injury risk but also performance aesthetics. Whole body vibration training (WBVT) is a new rehabilitation method that has been linked with improving balance and muscle function. 38 female dancers with self reported unilateral FAI were randomly assigned in 2 groups: WBVT and control. Absolute centre of mass (COM) distribution during single leg stance, SEBT normalised research distances and Peroneus longus mean power frequency (f(med)) where measured pre and post 6-week intervention. There was a significant improvement in COM distribution over the 6 weeks from 1.05 ± 0.57 to 0.33 ± 0.42 cm² (P<0.05), and 4 of the 8 planes of direction in the SEBT Ant, Antlat, Med and Antmed from 77.5 ± 7.1 to 84.1 ± 5.8% (P<0.05) compared to control groups during the course of the 6 week training intervention. There was no evidence of improvement in peroneus longus (f(med)) over time (P=0.915) in either group. WBVT improved static balance and SEBT scores amongst dancers exhibiting ankle instability but did not affect peroneus longus muscle fatigue.

One-year outcomes after retinal detachment surgery among medicare beneficiaries

PURPOSE

To determine longitudinal rates of second retinal detachment operation and postoperative adverse outcomes after retinal detachment surgery in a nationally representative sample of older Americans.

DESIGN

Retrospective, longitudinal cohort analysis.

METHODS

A total of 9216 Medicare beneficiaries were identified from the Medicare 5% sample who were diagnosed with rhegmatogenous retinal detachment and underwent primary pars plana vitrectomy (PPV), scleral buckle, pneumatic retinopexy, or laser photocoagulation or cryotherapy alone. Rhegmatogenous retinal detachment, PPV, scleral buckle, pneumatic retinopexy, or laser photocoagulation/cryotherapy was ascertained from International Classification of Diseases and Current Procedural Terminology procedure codes. Rates of second retinal detachment operation and postoperative adverse outcomes were analyzed by cumulative incidence and logistic regression to control for prior adverse outcome measures and demographic factors.

RESULTS

At 1-year follow-up, the rate of receipt of a second retinal detachment operation for beneficiaries who had undergone primary pneumatic retinopexy was much higher (40.6%, P < .0001) relative to the scleral buckle (19.2%) group. After controlling for demographic variables and ocular comorbidities, pneumatic retinopexy individuals were nearly 3 times more likely to receive a second retinal detachment surgery than scleral buckle individuals. No significant differences exist in risk of second retinal detachment surgery for the PPV compared to the scleral buckle group. Individuals receiving PPV were 2 times more likely to suffer adverse outcomes than were those undergoing scleral buckle. Results were robust in sensitivity analysis.

CONCLUSIONS

Rates of second operation were much higher after pneumatic retinopexy than PPV or scleral buckle, and rates of adverse outcomes were higher in PPV, even after controlling for risk factors and demographic variables.

Retinopathy of prematurity malpractice claims: the Ophthalmic Mutual Insurance Company experience

OBJECTIVE

To examine the causes of retinopathy of prematurity (ROP) malpractice claims filed with the Ophthalmic Mutual Insurance Company.

METHODS

All closed ROP malpractice claims were reviewed.

RESULTS

Eight cases involved failure of transfer of care on patient discharge from the hospital, 3 cases demonstrated inappropriately long periods between follow-up examinations, 1 case was due to failure of outpatient referral from screening to the treating ophthalmologist, and 1 case concerned unsupervised resident provision of ROP care.

CONCLUSIONS

Many preventable factors can be addressed to improve ROP care. It is essential to ensure that ophthalmologists, neonatologists, pediatricians, and families are updated on current guidelines for ROP screening and treatment and to facilitate follow-up appointments before patient discharge from the hospital. Doing so can help avoid future malpractice claims and patient harm.

Threadworm: an infrequent clinical finding in a genitourinary medicine clinic attendee presenting with ano-genital irritation

A 24-year-old lady presented to an evening genitourinary (GU) clinic with a short history of vulval and anal irritation. On perianal examination, several threadworms were visible. Symptoms resolved with oral mebendazole and strict personal and environmental hygiene. Threadworm is a common and easily treatable cause of pruritis ani, yet is underreported in GU literature. If the history is suggestive, consider performing the diagnostic cellophane test and/or prescribing empirical treatment.

Activity of antibiotics against Fusarium and Aspergillus

BACKGROUND/AIMS

To study the susceptibility of Fusarium and Aspergillus isolated from keratitis to amoxicillin, cefazolin, chloramphenicol, moxifloxacin, tobramycin and benzalkonium chloride (BAK).

METHODS

10 isolates of Fusarium and 10 isolates of Aspergillus from cases of fungal keratitis at Aravind Eye Hospital in South India were tested using microbroth dilution for susceptibility to amoxicillin, cefazolin, chloramphenicol, moxifloxacin, tobramycin and BAK. The minimum inhibitory concentration (MIC) median and 90th percentile were determined.

RESULTS

BAK had the lowest MIC for both Fusarium and Aspergillus. Chloramphenicol had activity against both Fusarium and Aspergillus, while moxifloxacin and tobramycin had activity against Fusarium but not Aspergillus.

CONCLUSIONS

The susceptibility of Fusarium to tobramycin, moxifloxacin, chloramphenicol and BAK and of Aspergillus to chloramphenicol and BAK may explain anecdotal reports of fungal ulcers that improved with antibiotic treatment alone. While some of the MICs of antibiotics and BAK are lower than the typically prescribed concentrations, they are not in the range of antifungal agents such as voriconazole, natamycin and amphotericin B. Antibiotics may, however, have a modest effect on Fusarium and Aspergillus when used as initial treatment prior to identification of the pathological organism.

Spontaneous resolution of a traumatic cataract caused by an intralenticular foreign body

A 49-year-old man presented with an intralenticular metal foreign body incurred while he was sawing wood. The metal chard had violated the lens capsule and was lodged in the cortex of the lens. It was removed using a lens-preservation technique during open-globe repair. Subsequently, a dense posterior cortical cataract developed, which spontaneously resolved over the ensuing months. The cataract had a cruciate configuration with wave-like disruption of the stromal lamellae. To our knowledge, this is the first case of spontaneous resolution of a cataract after capsule violation by an intralenticular foreign body. The unique appearance of the cataract and its unusual resolution led to a new theory of lens injury by shockwave.

The relationship between second-year medical students' OSCE scores and USMLE Step 2 scores

RATIONALE, AIMS AND OBJECTIVES

A valid tool to measure clinical competency early in medical school could identify students who may require special educational attention. The overall aim is to assess the relationship between students' scores on an objective structured clinical examination (OSCE) given in the second year of medical school and their subsequent performance on Step 2 of the United States Medical Licensing Examination (USMLE Step 2).

METHODS

Participants were 390 second-year medical students participating in a required OSCE; complete data (Medical College Admission Test, OSCE, USMLE Step 1 and Step 2 scores) were available for 340 students (87%). Univariate correlations and linear regression analyses were performed.

RESULTS

Total OSCE score was moderately correlated with USMLE Step 2 score (r = 0.395, P < 0.001), as were two skills subscores of the OSCE, differential diagnosis (r = 0.343, P < 0.001) and identification of abnormality (r = 0.322, P < 0.001). In linear regression analysis, neither OSCE total score nor any of the subscores independently predicted Step 2 scores; only Step 1 score (beta = 0.687, P < 0.001) and female sex (beta = 0.152, P < 0.001) remained independent correlates of Step 2 score.

CONCLUSION

OSCEs early in medical school can be useful in the early assessment of clinical competence.

Analysing sequential events in clinical trials

BACKGROUND

Data from clinical trials where the endpoint is a single survival time are readily analysed by standard methods, most commonly using a semi-parametric proportional hazards approach. However, when the outcome involves two sequential survival times, standard methods may not be applicable.

METHODS

We consider methods appropriate for the analysis of survival data in clinical trials where there are two distinct, sequential and opposing survival endpoints and where inferences about the second event are of particular interest. Two motivating examples of randomized clinical trials with different designs provide important illustrations of the methodology in practice.

RESULTS

Bivariate log-normal survival models are proposed as useful way of modeling such data. These models can be simply implemented in two stages, each of which is a univariate log-normal survival analysis. Different approaches to the analyses are described according to whether a second randomized treatment assignment is made at the time when the first event occurs and the second phase of the study commences. In the absence of a second randomization, the bivariate log-normal model adjusts for selection into the second phase of the study.

CONCLUSIONS

The investigation of 'treatment sequences' should, wherever possible, be handled by repeat randomization, which can then be followed by valid, unbiased analyses. However, in many clinical trial scenarios, this is simply not possible. In this case, the best approach is to consider the data as arising from an observational study, whilst controlling for all appropriate covariates.

LIMITATIONS

The approach we describe is appropriate for log-normally distributed data but could be generalised to handle other distributions, although the process of model fitting would be less straight-forward.

Post-exposure HIV prophylaxis following sexual exposure: a retrospective audit against recent draft BASHH guidance

OBJECTIVES

To retrospectively audit the management of post-exposure HIV prophylaxis following sexual exposure (PEPSE) against the British Association for Sexual Health and HIV 2004 draft guidance.

METHODS

A retrospective review of case notes from January 2000 to November 2004. The draft guidelines were not adopted into clinical practice during the study period.

RESULTS

76 patients received PEPSE. 79% (95% CI 68.08 to 87.46) of PEPSE prescriptions were given for exposures that were in accordance with the guidelines' recommended indications (target 90%). 87% (95% CI 77.13 to 93.51) of PEPSE was prescribed within 72 hours of risk exposure (target 90%). 91% (95% CI 81.94 to 96.22) of recipients received a recommended antiretroviral combination. 53% (95% CI 40.84 to 64.21) of recipients completed the PEPSE course (target 75%). 45% of patients attended for the 3 month follow up HIV test but only 12% (95% CI 5.56 to 21.29) attended for both the 3 month and 6 month HIV test (target 75%).

CONCLUSION

PEPSE is predominantly being prescribed for recommended indications and is dispensed within 72 hours of risk exposure. PEPSE completion rates and attendance for 3 months and 6 months post-exposure HIV testing need improving, perhaps by introducing a PEPSE clinic.

What happens to women who sell sex? Report of a unique occupational cohort

BACKGROUND/OBJECTIVES

Sex work has been seen as both a health and a social problem. However, there is a paucity of evidence on the longer term impact on health. We explored the health and career paths over a period of 15 years among women who have worked in the sex industry.

DESIGN

A longitudinal study of sex workers recruited between 1986 and 1993 and followed for 15 years. Outcome data were obtained through interview, clinic records, or third parties.

SETTING

Clinic and community settings in London.

PARTICIPANTS

We obtained outcome data on 130 (37%) of the original cohort of 354 women, with a combined follow up of 1247 years.

MAIN OUTCOME MEASURES

Vital status, most recent occupation, duration of sex work, sexually transmitted infections (STI), major health problems.

RESULTS

The majority (73/124, 59%) were still in the sex industry and had sold sex for a mean of 13.6 years. There were six deaths, a mortality of 4.8 per 1000 person years. Surviving women had a high cumulative risk (110 of 118, 93%) of STI. Past gonorrhoea was associated with pelvic inflammatory disease (RR 2.28, 95% CI 1.12 to 4.66) and infertility (RR 10.9, 95% CI 1.5 to 77.3). Other outcomes included mental health problems (38 of 97, 40%) and addiction (46 of 72, 64%). There were no significant differences in health outcomes between women who were still in the sex industry and those who had stopped. There was a high level of occupational mobility, and 31 women (of 84, 37%) had completed vocational or higher education, including eight to postgraduate level.

CONCLUSIONS

Sex work is associated with excess mortality and morbidity including the sequelae of STI, mental health problems, and substance misuse. The relation between these health problems and sex work is complex.

A phase II study of lapatinib (GW572016) in recurrent/metastatic (R/M) squamous cell carcinoma of the head and neck (SCCHN)

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Background: Epidermal growth factor receptor (EGFR) inhibitors have demonstrated reproducible activity in patients with R/M SCCHN. HER2 is the preferred dimerization partner for EGFR. Lapatinib is a dual EGFR and HER2 kinase inhibitor that has demonstrated promising preclinical activity in SCCHN models. Methods: This phase II multi-institutional study enrolls patients with R/M SCCHN into 2 cohorts: those without prior exposure to an EGFR inhibitor (arm A) and those with prior exposure to an EGFR inhibitor (arm B). All subjects were treated with lapatinib 1500mg OD. Primary endpoints were response rate (arm A) and progression-free survival (arm B). Results: 42 subjects have been enrolled (27 arm A, 15 arm B; 35 male, 7 female, median age 60 years). Toxicity was generally mild without any dose reductions or patient withdrawal due to adverse effects. Diarrhea was the most frequent toxicity occurring in 40% of patients. Other toxicities observed included fatigue (21%), rash (21%) and nausea (14%). 2 patients experienced grade 3 toxicity (1 diarrhea, 1 emesis). 1 patient had a reduction in left ventricular ejection fraction (60% to 40%) which was asymptomatic and recovered to baseline upon discontinuation of lapatinib. No objective responses were observed in either arm. In an intent-to-treat analysis stable disease was the best response observed in 37% of arm A and 20% of arm B subjects. Median PFS was 1.6 months in arm A and 1.7 months in arm B. Conclusions: Lapatinib as a single agent in R/M SCCHN, although well tolerated, appears to have little activity in either EGFR inhibitor naïve or refractory subjects.

No significant financial relationships to disclose.

How safe is safer sex? High levels of HSV-1 and HSV-2 in female sex workers in London

Female sex workers in Europe have low levels of sexually transmitted infections, attributable to condom use. The aim of this paper is to describe the seroepidemiology of HSV-1 and HSV-2 in female sex workers in London by using a 15-year prospective study of 453 sex workers. The seroprevalence of HSV-1 was 74.4% and independently associated with birth in a 'transitional country' (OR 5.4, 95% CI 1.61-18.20). The seroprevalence of HSV-2 was 60% and declined over time; it was also independently associated with time in sex work (OR 2.12, 95% CI 1.23-3.65) and birth in a 'developing country' (OR 2.95, 95% CI 1.34-6.48). We show that a cohort of sex workers with extensive condom use and little known sexually transmitted infection have high levels of HSV-1 and HSV-2 infection, suggesting that condoms may not be universally protective. Sex workers are candidates for HSV vaccine efficacy or intervention studies.

Identification of a novel HLA-A allele (A*1115) in the UK National External Quality Assessment Schemes for Histocompatibility and Immunogenetics' Educational Cell Exchange

The novel allele, HLA-A*1115, was identified in an 'Educational Scheme' sample (ED03/03 - from a north-western European Caucasoid blood donor) distributed by the UK National External Quality Assessment Schemes for Histocompatibility and Immunogenetics. ED03/03 was typed by serology, the polymerase chain reaction using sequence-specific primers and sequence-based typing. A*1115 is most similar to A*110101 with a single mismatch (G to C) at constant position 565, leading to a conservative amino acid change from valine (GTG) to leucine (CTG) at codon 165 in the alpha(2) domain. This substitution has not been reported for any other HLA class I allele so far. The HLA-A*1115-bearing haplotype was B*350101; Cw*040101; DRB1*140101; DRB3*020201; DQA1*010401; DQB1*0503; DPA1*0103/07; DPB1*030101. Extensive serological typing indicated that this allele essentially encodes a 'normal' HLA-A11 specificity.

HLA-DQB1 sequencing-based typing using newly identified conserved nucleotide sequences in introns 1 and 2

Sequencing-based typing (SBT) human leukocyte antigen (HLA) class I and II genes should examine entire exon sequences where polymorphisms lie. Primers for the amplification of complete exons therefore anneal in introns and their design relies on accurate intron sequences being available. We decided to develop a SBT method for HLA-DQB1 using amplification primers which anneal in introns 1 and 2, yet the amount of intron sequence data previously available in databases was sparse. Therefore, we undertook a systematic sequencing of introns 1 and 2 using DNA from cell lines homozygous for DQB1. This study confirmed an earlier report that the non-coding regions of this gene are the most polymorphic seen in the human genome. Intron sequences within an allele group were largely identical, the exceptions being DQB1*0301 differing from other DQB1*03 allele groups and DQB1*0601 differing from all other DQB1*06 alleles. A retroviral Alu element, related to the AluYa5a2 subfamily, was identified uniquely inserted in intron 2 of DQB1*02 alleles. For the typing approach, six amplification primers were designed based on conserved allele group sequences covering all of the HLA DQB antigens, and two sequencing primers were also designed which anneal in intron 2. This method has proved to be very robust and has been used as part of a referral DNA sequencing service for a number of years.

A new HLA-A Allele, HLA-A*6824, identified in three unrelated individuals*

A novel allele, human leukocyte antigen (HLA)-A*6824, has been identified in three unrelated individuals of northwestern European origin in a period of less than 4 months, implying that this allele may be quite common in this population. HLA-A*6824 differs from A*680102 by a single nucleotide change at position 275 in exon 2, which results in a conservative amino acid substitution from lysine to arginine in the peptide-binding groove at codon 68.

Declining prevalence of STI in the London sex industry, 1985 to 2002

OBJECTIVES

To describe major changes in the London sex industry between 1985 and 2002 and assess the implications for sexually transmitted infection (STI) risk.

METHOD

A descriptive study comparing women who first attended a sex work clinic between 1996 and 2002 and those first attending from 1985 to 1992; a nested case-control study. 1050 female sex workers took part. The setting was a specialist clinical service for sex workers based in a London genitourinary medicine (GUM) clinic, and fieldwork in west London. The main outcome measures were reported condom use and prevalent STI.

RESULTS

Over the period of the study there was a significant increase in the proportion of sex workers not born in the United Kingdom (from 25% to 63%, p < 0.001), and women entered sex work at an older age (median 24 years compared with 20 years, p < 0.001). Condom use increased (with the exception of oral sex). There was a significant decline in the proportion of participants reporting a previous STI (32% compared with 80%, p < 0.001) and the prevalence of acute STI declined from 25% to 8% (p < 0.001). Acute STI was associated with younger age, younger age at first sex work, being new to sex work, and inconsistent condom use. In a multivariate analysis unprotected sex with clients was the only significant risk.

CONCLUSION

Major restructuring of the sex industry, including the shift to a primarily migrant workforce, has been associated with a steep decline in acute STI, undermining popular assumptions that migrant sex workers are central to the ongoing STI epidemic. We attribute the decline in acute STI to an increase in safer sex.

Improving uptake of HIV testing in patients with a confirmed STI

Up to 70% of GU clinic attendees with a sexually transmitted infection (STI) and undiagnosed HIV, remain HIV undiagnosed after their visit. STIs have been shown to facilitate HIV transmission. Therefore, patients with an STI should test for HIV. Our objective was to compare the uptake of HIV testing in GU clinic attendees with an STI (study group) with those receiving a negative GU screen (control group). This re-audit was performed after introduction of the following clinic changes: nurse-performed asymptomatic GU screening; 'opt-out' HIV testing policy; discontinuing routine pre-HIV test counselling; access to HIV results by post. The uptake of HIV testing overall, and in the study and control groups respectively was 53% (n = 573), 41% (n = 285) and 65%, showing significant improvement compared to the first audit in 1999 (18%, 14% and 33% respectively) (P < 0.01). The clinic interventions increased HIV testing rates which were in keeping with National Sexual Health strategy targets.

Establishment of Serratia entomophila after application of a new formulation for grass grub control

The bacterium Serratia entomophila is a naturally occurring pathogen causing amber disease of the New Zealand grass grub (Costelytra zealandica) A novel granular formulation of S entomophila Bioshieldtrade; was applied to 18 pasture sites in a largescale programme to demonstrate efficacy against grass grub No significant difficulties were encountered in application of the granules through conventional machinery There were high populations of the applied bacteria in soil within the first week of application and within 6 weeks of application there was an average of 3 x 104 viable S entomophila of the applied strain per gram of soil This resulted in a significant (Plt;005) 20 increase in the incidence of amber disease in the treated grass grub populations compared to untreated populations Successful establishment of the bacteria in the soil and target population following Bioshieldtrade; granule application was demonstrated on a wide range of sites under various farming conditions

Identification of a new allele, HLA-DRB1*1360, on a DRB5 haplotype in a Brazilian individual

The application of DNA-based methods for human leukocyte antigen (HLA) genotyping has revealed an ever-increasing degree of polymorphism within the HLA-DRB loci and has resulted in the discovery of new alleles. We have identified a new DRB1 allele that was subsequently named DRB1*1360 by the WHO Nomenclature Committee. This allele is unusual for a DRB1*13 allele, as it is present on a DRB5 haplotype rather than the normal DRB3 haplotype found in association with DRB1*13 alleles.

Progressive increase in incidence and prevalence of multiple sclerosis in Newcastle, Australia: a 35-year study

The prevalence of multiple sclerosis (MS) in Newcastle, Australia increased significantly between 1961 and 1981 and the incidence of the disease also increased between the decades 1950-1959 and 1971-1981. The present study sought to determine whether there has been a further increase in the frequency of MS in the subsequent 15 years, and to examine the potential factors underlying this change. The incidence, prevalence and clinical profile of multiple sclerosis were therefore re-examined in Newcastle, Australia in 1996 using comparable diagnostic criteria and methods to those employed in studies in the same region in 1961 and 1981. There has been a significant progressive increase in prevalence from 19.6 to 59.1 per 100,000 population and a significant increase in incidence from 1.2 to 2.4 per 100,000 population from 1961 to 1996. The most pronounced increase in prevalence was in females and in the age-group over 60 years, and there was also an increased incidence in females aged 20-29 years. There was little change in the age of disease onset, but duration of disease in females had increased substantially. The significant increase in prevalence is attributed to increased incidence, particularly in females; and to increased survival. Although such trends in prevalence have been observed in the Northern Hemisphere, this is the first such study in the Southern Hemisphere to show a longitudinal increase in prevalence and incidence over a period of this duration.

A new allele, HLA-DRB4*010304

We report here the identification of a novel DRB4*01 allele, DRB4*010304, found in a patient waiting for a liver transplantation. The new allele was detected during a routine DNA-based HLA typing. Sequencing confirmed that the new allele is identical to DRB4*01030101 at exon 2 except for position 216 where the new allele has a T instead of a C.

Identification of HLA alleles with low or no cell surface expression in the Czech population

The presence of the A*24020102L allele is implicated in one donor from the CBMD who serologically was typed as A2; B44, B55; Cwl, Cw7. The DRB4*01030102N allele was identified in one healthy donor and in one patient with MDS during routine HLA class II DNA typing. The DRB4*01030102N allele was identified in the patient's father, who had CML, and was associated with the HLA-A3-B7-Cw7-DRB1*0701-DQB1*0303 haplotype, which is common for European populations. In order to avoid mistyping, both techniques, serology and molecular biology must be used for HLA typing, especially for cases where just one antigen appeared to be present using serological methods.

Identification of two new alleles in a single Korean individual, HLA-B*1568 and HLA-DRB1*1208

We have identified a new HLA-B*15 allele and a new HLA-DRB1*12 allele, named B*1568 and DRB1*1208, respectively. The alleles were identified using a combination of sequence specific primers, reverse line sequence specific oligonucleotide probing and sequence-based typing. Both alleles were identified in a single individual of Korean origin. HLA-B*1568 appears to be an HLA-B*4801/B*1507 hybrid combining the exon 2 sequence of B*4801 and the exon 3 and 4 sequences of B*1507. Exon 2 of DRB1*1208 was most similar to DRB1*1201 or 1206, with a single mismatch at nucleotide position 165 (A to C). At the protein level, this substitution results in a phenylalanine substitution at position 26 that creates an identical amino acid sequence to DRB3*0202 between amino acid positions 17 and 36.

Identification of a new HLA-B*15 allele, HLA-B*1569

We have identified a new HLA-B*15 allele (B*1569) by polymerase chain reaction (PCR) using sequence-specific primers (SSP) and sequence-based typing (SBT). This novel allele was found in a 67-year-old white Caucasian male and differs from HLA-B*1503 at 3 positions. The nucleotide substitutions at positions 544, 559 and 560 result in amino acid changes at codon 158 from GCC (alanine) to ACC (threonine), and at codon 163 from CTG (leucine) to ACG (threonine).

Attitudes towards intramural continuing medical education: a european perspective

Continuing medical education (CME) is now one of the key areas of development in medical education. This paper describes the development of an intramural continuing medical education programme de novo in a newly opened cancer institute in Italy, which provided a unique opportunity to study attitudes towards the concepts and goals of continuing medical education as most of the individuals involved in this programme were exposed to continuing medical education for the first time. The continuing medical education programme was overseen by a CME committee for 1 year. Three 1-hour sessions were delivered each week and one credit point was awarded for each session. The sessions included grand rounds, clinical-based teaching and a 3-weekly rotating schedule of pathology, radiology and research. Participants were all the medical doctors attending the European Institute of Oncology. Attendance at greater than 50% of the total sessions available yearly qualified the individual for certification by the CME committee of the Institute. A questionnaire was circulated to all medical doctors at the Institute at the end of the academic year to assess attitudes to CME in general. Forty-six out of 84 questionnaires were returned. The majority of those involved in this CME intramural programme undertook self-directed CME activities and at least 50% had not previously attended either grand rounds or research seminars. Most felt that CME should not be mandatory but that its activities should be monitored. The greatest difficulty with CME was in its timing.

Metabolism of rabbit angiostatin glycoforms I and II in rabbits: angiostatin-I leaves the intravascular space faster and appears to have greater anti-angiogenic activity than angiostatin-II

Plasminogen (PLG) exists in the circulation as two glycoforms, I and II. Angiostatin (AST) is a polypeptide that has been cleaved from the kringle region of PLG and has strong anti-angiogenic properties. AST-I and AST-II, which consisted only of kringles 1 through 3, were prepared by the action of urokinase on purified rabbit PLG-I and PLG-II, respectively, in the presence of N-acetyl cysteine, followed by affinity chromatography on lysine-Sepharose. Purified AST-I and AST-II were tested for functional activity with a chick chorioallantoic membrane (CAM) model; when similar amounts were applied to a 6-day CAM, AST-I was substantially more effective than AST-II in decreasing vascular supply to the CAM over a 72-hour period; this activity correlated with a loss of capillaries, probably through apoptosis of endothelial cells. Radiolabeled AST-I and AST-II (iodine 125 and iodine 131) were co-injected intravenously into healthy rabbits to determine their clearances from plasma measured over 3 days. Over a dose range of 0.08 to 2.7 microg/kg, the fractional catabolic rate within the intravascular space (j(3)) indicated that AST-I was cleared 3-fold to 4-fold more rapidly than AST-II (P < .001). The catabolic half-life of AST-I (2.01 +/- 0.19 days) was significantly less than that of AST-II (2.62 +/- 0.20 days). The faster clearance of AST-I from the intravascular space was matched by its more rapid passage than AST-II to the extravascular space of various organs over 60 minutes in vivo. This property of AST-I as compared with AST-II may partially explain its greater anti-angiogenic potential. From the plasma concentrations of PLG-I and PLG-II and their relative behaviors toward rabbit VX-2 lung tumors in vivo, we predict that substantially greater quantities of AST-II than AST-I may be released into the extravascular space of tumors.

What did we learn about national organizational collaboration at the advisory committee level?

This article provides an overview of the typical roles and tasks of advisory groups in general, followed by a discussion of the roles and tasks the Interdisciplinary Generalist Curriculum (IGC) Project Advisory Committee was asked to assume and how these were fulfilled. It analyzes the lessons learned about advisory committees as a result of the IGC Project experience. Key elements of success in fulfilling advisory committee obligations include well-defined expectations, periodic evaluations, and clear communication between project leadership and the members of the advisory committee. In the spirit of lessons learned from the IGC Project, this critique identifies several philosophical and logistic issues that might be considered in the design and implementation of future projects, such as the need to choose committed, high-energy advisory committee members who are willing to perform many complex, time-consuming tasks.

Metastatic soft tissue squamous cell carcinoma

Metastatic squamous cell carcinoma of the soft tissue is extremely rare. We report two patients with soft tissue metastasis from squamous cell carcinoma of the cervix in one and scalp in another. Case 1: A 63-year-old black woman with a history of cervical cancer presented with a painful mass over the right scapula. An incisional biopsy revealed squamous cell carcinoma. She underwent radiation treatment followed by wide local excision with en bloc resection and a myocutaneous flap closure. Case 2: A 46-year-old white man with a history of squamous cell carcinoma of the scalp and two kidney transplantations requiring long-term immunosuppression presented with a 2-month history of a left proximal arm mass. Magnetic resonance imaging revealed that the mass was within the triceps muscle and fixed to the humerus. Biopsy revealed squamous cell carcinoma. He underwent a shoulder disarticulation for tumor invasion into the adjacent humerus and neurovascular bundles. The patients remain disease-free at 12 and 8 months, respectively. To our knowledge there are no reports of soft tissue squamous cell carcinoma metastatic from the cervix and only rare cases from the lung, head, and neck. The optimal mode of treatment and prognosis is undefined in these patients because of its rare incidence. Surgery and radiation with curative intent were used.

Application of rat hepatocyte culture to predict in vivo metabolic auto-induction: studies with DFP, a cyclooxygenase-2 inhibitor

The drug candidate DFP [5,5-dimethyl-3-(2-isopropoxy)-4-(4-methanesulfonylphenyl)-2(5H)-furanone] is a selective cyclooxygenase-2 inhibitor under evaluation for analgesic and anti-inflammatory therapy. The in vitro metabolic pathways (rat microsomes) involve hydroxylation of the isopropyl side chain at either of two positions, the methyl or the methine, thus producing a hydroxylated metabolite (DFHP) or a dealkylated metabolite (DFH). DFH formation was the major pathway. Using hepatic microsomes from rats treated with agents that induce specific CYP isozymes, it was shown that the dexamethasone-inducible rat CYP3A isozyme(s) play a major role in DFH formation. The roles of CYP3A1 and -3A2 were confirmed with genetically engineered rat CYP enzymes. The potential for induction of rat CYP3A by DFP was evaluated by incubating DFP in rat hepatocyte cultures and measuring the CYP3A levels. Both CYP3A immunoreactive protein and enzyme activity were induced in a dose-dependent manner. The induction was confirmed in vivo by dosing rats with DFP at 100 mg/kg for 4 days. Microsomes prepared from the excised livers showed that DFP gave approximately 55% of the induction observed with dexamethasone, as determined by Western blot. In vitro metabolic auto-induction of DFP was assessed by measuring the metabolism of DFP in hepatocytes treated with DFP. DFH formation was significantly enhanced in the DFP-treated cells. In vivo, treating rats with DFP at doses of 10 to 100 mg/(kg.day) for 13 weeks indicated that DFP induced its own metabolism. The C(max) and plasma drug area under the curve values during the thirteenth week were significantly lower than that on the first day, and the effect was dose-dependent.

Gastrointestinal stromal tumors: analysis of clinical and pathologic factors

Gastrointestinal mesenchymal tumors have been classified as benign (leiomyoma) or malignant (leiomyosarcomas). More recently, these tumors have been termed gastrointestinal stromal tumors (GISTs). GISTs have a highly variable clinical course. This review analyzes the clinical presentation, pathologic examination, and long-term follow-up of patients with GIST. A retrospective analysis of the clinical course of patients with GIST at a single institution from 1986 to 1998 was performed. Nineteen patients with GIST (12 gastric, two duodenal, three jejunal, and two rectal) were treated. The most common clinical presentation was gastrointestinal bleed. CT scans, contrast studies, and endoscopy were used to identify a tumor mass. Diagnosis of GIST was made in only two patients preoperatively. Tumor size ranged from 0.8 to 23 cm. Histology of the tumors was variable. All patients underwent surgical resection with curative intent. Follow-up ranged from 2 to 55 months. There were two perioperative deaths. Local recurrence occurred in one patient. GISTs are uncommon. Preoperative diagnosis can be difficult, and often the diagnosis is made at the time of surgery. With complete resection of the tumor the clinical course is favorable with very few local recurrences. Therefore complete resection of the tumor is recommended.

Parental health beliefs and compliance with prophylactic penicillin administration in children with sickle cell disease

PURPOSE

Prophylactic penicillin is effective in preventing severe invasive pneumococcal infection in children with sickle cell disease. In some families, compliance has been problematic. The aims of this study were to monitor compliance and to assess the efficacy of the Health Belief Model (HBM) in predicting compliance.

METHODS

Fifty mothers of children with sickle cell disease, ages 6 to 60 months, participated in the study. On enrollment, mothers completed surveys assessing their health beliefs regarding sickle cell disease and infections. Compliance was assessed through self-reporting by the mothers and through review of local pharmacy records of penicillin refills.

RESULTS

Sixty percent of the mothers reported that they were highly compliant with obtaining the prescribed 14-day refills. Pharmacy records indicated that only 12% actually adhered to this schedule. The self-reports were significantly related to compliance ratings; mothers who admitted less than optimal compliance averaged 42 days between refills, compared with 19 days for mothers who reported good compliance. Varying perceptions identified through the HBM accounted for approximately 30% of the variance in compliance rates. The perceived burdens of picking up the refills and remembering to administer the medication were the most significant factors.

CONCLUSIONS

Educational efforts alone are not sufficient to ensure compliance with penicillin prophylaxis. Routinely monitoring compliance through pharmacy records, reviewing parental beliefs about sickle cell disease and infections, and exploring barriers to treatment will promote dialogue about the importance of strict compliance with this relatively simple yet life-saving prophylaxis.

Fatigue-related changes in electomyogram activity of the cat gastrocnemius during frequency-modulated efferent stimulation

Changes in the compound muscle action potentials of cat gastrocnemius muscle were studied during low- and high-frequency fatigue. Fatiguing session consisted of 25-28 repetitions of the standard single fatigue tests (1.5min interval between the tests) that included the part of continuous frequency-modulated stimulation preceded and followed by single stimuli evoking twitch contractions in the muscle. The rate of the continuous part was changed in accordance with symmetrical double-trapezoidal signal, including three successive phases of constant rate at 10, 40 and 10s(-1); between these phases of 4s duration the rate changed linearly within a 2s interval. During fatigue relative changes in compound muscle action potential waves were usually smaller than changes in tension. Within the same fatigue procedure applied to a fresh muscle, the drop in tension was as much as 35% for high-rate stimulation and 59-71% for low-rate stimulation, whereas the decrease of the peak-to-peak compound muscle action potential waves amplitudes did not exceed 10-20%. Compound muscle action potential waves underwent the most pronounced depression during high-rate stimulation, the decrease proceeding during the following phase of low-rate stimulation. The tension changes during long-lasting activation were different for low- and high-frequency fatigue, with more pronounced depression during low-rate stimulation. As a rule, compound muscle action potential waves changes followed opposite patterns. Compound muscle action potential waves progressively split up, which was probably associated with a continuous slowing of the action potentials in the most fatigable motor units and the subsequent disappearance of the reactions at least in part of the motor units. Hysteresis effects in muscle contraction seem to be able, at least in part, to compensate for some of the depressive effects appearing during conduction of action potentials in muscle fibres. Changes in the compound muscle action potentials were studied during development of the muscle fatigue. These changes showed pronounced dependency on stimulation rate allowing differentiating effects of low- and high-frequency stimulation of the efferents supplying muscle under study. At the same time the fatigue-related changes in the action potentials were noticeably smaller than changes in tension, thus supporting existing concepts in the field arguing that fatigue effects are mainly connected with corresponding activity-dependent changes in muscle contraction machinery.

How to select covariates to include in the analysis of a clinical trial

The comparisons of treatments in randomized clinical trials may use the analysis of covariance to adjust for patient characteristics. We present theoretical results that describe when such an adjustment would be expected to be beneficial. A distinction is made between covariates that are balanced in the design and those that are assigned by the randomization process. The results support the commonly held view that features balanced in the design of the trial (e.g., by stratification) and those that are strongly predictive of the outcome, and thus considered clinically prognostic, should normally be included in the analysis. For other covariates that are not balanced in the design, the potential benefits of including them in the analysis will depend on the number of patients in the trial. However, there is frequently a set of variables whose relevance is unknown and for which data-dependent methods of selection, based on the data for the current trial, have been proposed. A review of the literature has shown that these methods can produce misleading inferences. The decision as to which covariates to include in the analysis should be specified in the protocol on the basis of data from previous trials on similar patient populations. The methods are illustrated with data from a trial comparing two therapies for treating scalp psoriasis where the clinical importance of patients' age and sex as prognostic factors for efficacy is unknown. We show for what size of future trials it would be beneficial to adjust for these covariates and for what size trials it would not. In all cases, prespecification of variables to be included in the analysis is essential in order to avoid bias.

Identification of a new HLA-B*39 allele: HLA-B*3924

We have identified a new HLA-B*39 allele through polymerase chain reaction (PCR) using sequence-specific primers (SSP) and sequence-based typing of exons 2 and 3. This novel allele was identified in three HLA-identical siblings of Turkish origin. This allele only differs from HLA-B*3903 at a unique single nucleotide substitution (T for C) at position 365 in exon 3 which results in an amino acid change in codon 98 of methionine (ATG) to threonine (ACG). The sequencing enabled the development of a monospecific PCR-SSP reaction which can be used to discriminate between HLA-B*3924 and other B*39 alleles.

Health issues associated with increasing use of "crack" cocaine among female sex workers in London

OBJECTIVES

To document changes in "crack" cocaine use in the sex industry in London, and to assess health risks associated with the drug.

DESIGN

Two serial cross sectional surveys.

SUBJECTS

Sex workers interviewed in 1989-9 and 1995-6.

MAIN OUTCOME MEASURES

Self reported use of crack cocaine; clinical history of sexually transmitted infection and pregnancy, clinical outcomes.

RESULTS

The proportion of women reporting crack use increased significantly from 22/193 (11%) in 1989-91 to 48/143 (34%) in 1995-6. Women in all the main prostitution sectors reported crack use. Crack users had been working in prostitution for longer, were more likely to have worked on the streets, to inject drugs, and to have a partner who injected. Crack use was associated with termination of pregnancy and with hepatitis C infection. The association with hepatitis C was partially explained by confounding with injecting drug use.

CONCLUSIONS

Crack use is more common and less problematic than clinical presentation suggests. Use has increased over the past decade, and is associated with hepatitis C infection and termination of pregnancy. It is possible that crack use facilitates hepatitis C transmission due to oral lesions from smoking. Crack use can be difficult to identify because of the stigma of being labelled a "crack whore," therefore information on crack might usefully be integrated into general health promotion material on drugs and safer sex.