Protection against nerve agent poisoning by a noncompetitive nicotinic antagonist

The acute toxicity of organophosphorus (OP) nerve agents arises from accumulation of acetylcholine (ACh) and overstimulation of ACh receptors. The mainstay of current pharmacotherapy is the competitive muscarinic antagonist, atropine. Nicotinic antagonists have not been used due to the difficulties of administering a dose of a competitive neuromuscular blocker sufficient to antagonise the effects of excessive ACh, but not so much that it paralyses the muscles. An alternative approach would be to use a noncompetitive antagonist whose effects would not be overcome by increasing ACh concentrations. This study demonstrates that the compound 1,1'-(propane-1,3-diyl)bis(4-tert-butylpyridinium), which blocks open nicotinic ion channels noncompetitively, is able to reverse the neuromuscular paralysis after nerve agent poisoning in vitro and to protect guinea pigs against poisoning by nerve agents when used as part of a therapeutic drug combination including a muscarinic antagonist. In contrast to the oxime HI-6, this compound was equally effective in protecting against poisoning by sarin or tabun. Further studies should identify more effective compounds with this action and optimise doses for protection against nerve agent poisoning in vivo.

Postprandial metabolism of Pacific bluefin tuna (Thunnus orientalis)

Specific dynamic action (SDA) is defined as the energy expended during ingestion, digestion, absorption and assimilation of a meal. This study presents the first data on the SDA response of individual tunas of any species. Juvenile Pacific bluefin tunas (Thunnus orientalis; body mass 9.7–11.0 kg; N=7) were individually fed known quantities of food consisting primarily of squid and sardine (meal energy range 1680–8749 kJ, ~4–13% of tuna body mass). Oxygen consumption rates () were measured in a swim tunnel respirometer during the postprandial period at a swimming speed of 1 body length (BL) s−1 and a water temperature of 20°C. was markedly elevated above routine levels in all fish following meal consumption [routine metabolic rate (RMR)=174±9 mg kg−1 h−1]. The peak during the SDA process ranged from 250 to 440 mg kg−1 h−1 (1.5–2.3 times RMR) and was linearly related to meal energy content. The duration of the postprandial increment in ranged from 21 h to 33 h depending upon meal energy content. Consequently, the total energy used in SDA increased linearly with meal energy and ranged from 170 kJ to 688 kJ, such that the SDA process accounted for 9.2±0.7% of ingested energy across all experiments. These values suggest rapid and efficient food conversion in T. orientalis in comparison with most other fishes. Implanted archival temperature tags recorded the increment in visceral temperature (TV) in association with SDA. returned to routine levels at the end of the digestive period 2–3 h earlier than TV. The qualitative patterns in and TV during digestion were similar, strengthening the possibility that archival measurements of TV can provide new insight into the energetics and habitat utilization of free-swimming bluefin in the natural environment. Despite efficient food conversion, SDA is likely to represent a significant component of the daily energy budget of wild bluefin tunas due to a regular and high ingestion of forage.

Selection of peptide ligands for the antimucin core antibody C595 using phage display technology: definition of candidate epitopes for a cancer vaccine

Aims-To further define the specificity of the antimucin core antibody C595 by fitting it with a family of hexapeptide ligands by immunoselection of filamentous bacteriophage from a gene III display library of approximately 6.4 x 10(7) random hexapeptides.Methods-Three rounds of immuno-selection were used to enrich for C595 binding phage. DNA sequencing revealed the hexapeptides expressed. Bacteriophage and corresponding synthetic hexapeptides were used in ELISA assay to determine binding affinities.Results-Twenty nine clones from this selected population were analysed. Seven contained the natural epitope RPAP, encoded by two different DNA sequences; 17/29 contained the motif RLPP. In all, 28/29 clones contained the motif RXXP and one clone (RVRPAP) contained the motif RXXP in two peptidic registers; 24/28 clones (6/8 DNA sequences) contained a hydrophobic residue (V or I) at position 1 relative to the RXXP motif. In addition the proximity of RXXP to glycine (position 5) suggests that this contributes in the natural epitope to antibody/antigen binding, which was not detected by chemical synthetic methods. One clone, KSKAGV, bears no obvious relationship to the natural epitope and therefore qualifies as a weakly binding mimotope.Conclusions-This approach has rapidly defined the specificity of this antibody in unprecedented detail, and provides a more comprehensive molecular basis for exploring the immune recognition of the MUC1 mucin by the C595 antibody. Importantly, the novel but related epitopes seen provide peptide specificities and a strategy which may prove useful in generating cancer vaccine candidates.

The fate of elderly patients discharged from the accident and emergency department of a general teaching hospital

This paper describes the experience of a cohort of elderly patients who were discharged after attending the accident and emergency department of a large Australian teaching hospital. Before-and-after comparisons of aspects of physical functioning revealed a considerable loss of independence in the period immediately after the visit to the hospital. Subsequent hospital admission or death was observed in 30 of the 90 patients studied. It is suggested that elderly patients discharged from the accident and emergency department are at risk and require special consideration and a high index of suspicion in terms of evaluation at the time of presentation. Before discharge, account should be taken of aspects of physical and mental function, social networks, and community supports available to each patient. A lowered threshold for admission is recommended on the basis of the high rate of return found in this study.

Sensitivity and specificity of HIV rapid tests used for research and voluntary counselling and testing

BACKGROUND

HIV rapid tests (RT) are a quick and non-technically demanding means to perform HIV voluntary counselling and testing (VCT) but understanding their limitations is vital to delivering quality VCT.

OBJECTIVE

To determine the sensitivity and specificity of HIV rapid tests used for research and voluntary counselling and testing at four sites in East Africa.

DESIGN

Cross-sectional study.

SETTING

Masaka District, Uganda; a sugar plantation in Kakira, Uganda; Coastal Villages in the Kilifi District of Kenya; and the Urban slum of Kangemi located West of Nairobi, Kenya.

SUBJECTS

Six thousands two hundred and fifty five consenting volunteers were enrolled into the study, and 675 prevalent HIV infections were identified.

RESULTS

The RT sensitivity tended to be high for all assays at all sites (97.63-100%) with the exception of the Uni-Gold assay (90.24% in Kangemi, 96.58% in Kilifi). Twenty four RT results were recorded as 'weak positives', 22 (92%) of which were negative by ELISA. There was a high rate of RT false positives in Uganda (positive predictive values ranging from 45.70% to 86.62%).

CONCLUSIONS

The sensitivity and specificity of the RT varied significantly across sites. The rate of RT misclassification in Uganda suggests that a multiple test algorithm may be preferable to a single test as screener for HIV VCT.

Bispectral Index asymmetry and COMFORT score in paediatric intensive care patients

BACKGROUND

The Bispectral Index (BIS) monitor has been suggested as a potential tool to measure depth of sedation in paediatric intensive care unit (PICU) patients. The primary aim of our observational study was to assess the difference in BIS values between the left and right sides of the brain. Secondary aims were to compare BIS and COMFORT score and to assess change in BIS with tracheal suctioning.

METHODS

Nineteen ventilated and sedated PICU patients had paediatric BIS sensors applied to either side of their forehead. Each patient underwent physiotherapy involving tracheal suctioning. Their BIS data and corresponding COMFORT score, assessment as by their respective nurses, were recorded before, during, and after physiotherapy.

RESULTS

Seven patients underwent more than one physiotherapy session; therefore, 28 sets of data were collected. The mean BIS difference values (and 95% CI) between left BIS and right BIS for pre-, during, and post-physiotherapy periods were 9.2 (5.9-12.5), 15.8 (11.9-19.7), and 7.5 (5.2-9.7), respectively. Correlation between mean BIS, left brain BIS, and right brain BIS to COMFORT score was highly significant (P<0.001 for all three) during the pre- and post-physiotherapy period, but less so during the stimulated physiotherapy period (P=0.044, P=0.014, and P=0.253, respectively).

CONCLUSIONS

A discrepancy between left and right brain BIS exists, especially when the patient is stimulated. COMFORT score and BIS correlate well between light and moderate sedation.

Impact of risperidone long acting injection on resource utilization in psychiatric secondary care

Risperidone long acting injection (RLAI) is the only long acting atypical antipsychotic available in the UK. Its impact on NHS resource use has not been widely studied. This review of medical records was conducted to quantify the impact of RLAI on NHS psychiatric secondary care resource use, primarily in terms of episodes of inpatient hospital care 12 months before and 12 months after RLAI initiation. Data on number of hospitalizations and hospital bed days were collected retrospectively, from patient notes and hospital databases in four acute psychiatric units in the UK for all individuals with a diagnosis of schizophrenia or schizoaffective disorder who were prescribed RLAI more than 12 months previously. Data were collected on 100 individuals (58 male) with a mean age 40.8 years (range 19-70). The median duration of illness before RLAI initiation was 12 years (range six months to 43 years). There were 62 admissions in the 12 months pre-RLAI, falling to 22 admissions in the 12 months post-RLAI. Number of admissions, we argue, offer a more reliable indicator of the impact of treatment than total hospital bed days in this type of study. In this study there were 40 fewer admissions in the 12 months after RLAI was initiated compared with the previous 12 months. This is important as readmission is a good proxy measure of relapse, and adherence to medication is known to be a key factor in relapse prevention.

An analysis quantifies prostate brachytherapy swelling using peripheral seeds as fiducial reference points

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Background: Permanent prostate brachytherapy (PPB) assesses implant quality but may suffer significant variability due to: 1) Prostate edema may occur during the procedure which usually subsides within several months, and 2) interobserver variability of CT- derived prostate volumes. An analysis is described, which uses the seeds as prostate fiducials to produce an implant reference volume (IRV). The ratio of the IRV volumes at day 0 and day 33 provides a unique way to quantify prostate edema; thus reducing this factor as a source of variability. Methods: Thirteen low risk prostate cancer patients, (Stage ≤ T2, PSA<13.9, Gleason Score ≤7) were implanted with 125Iodine seeds (77% stranded; prescription dose of 145 Gy). PPB was completed for each patient on day 0 and 33 ±3 days following the implant. The IRV was defined as the volume obtained by contouring the outer most peripheral seeds, circumferentially, on each axial image, resulting in a 3D volume. Contouring was performed by three separate investigators (KJM, DCG, EKM), who were blinded with respect to patient identification. The IRV's were compared both by investigator and by time of PPB (day 0 vs. day 33). The radiation dose encompassing 90% (D90) of the IRV and Prostate (PST) was calculated and compared . Results: The IRVs contoured were reproducible between the investigators with a maximum mean difference of .56 (SD .33) cc. There was no statistical difference between any of the investigators contoured volume (minimum Spearman correlation was 0.978). The average IRV was significantly larger on day 0 (Avg. 52.7;SD 19.7 cc) compared to day 33 (Avg. 44.6; SD 19.1 cc) (p<0.001). The day 0 IRV was an average of 1.18 times larger than the Day 33 PRV. There was no difference between either the day 0 D90PST (Avg.149.1; SD18.7 cGy) vs the day 0 D90IRV (Avg.149.8, SD 27.5 cGy) (p=.442) nor between the day 33 D90PST (Avg.163.7; SD22.7 cGy) vs the day 33 D90IRV (Avg.166.6, SD 30.3 cGy) (p=.257). Both the D90IRV and D90PST were significantly different at day 0 vs 33 (p=.0003, p=<.0001 respectively). Conclusions: The IRV analysis demonstrates no significant interobserver variability, provides accurate quantification of prostate swelling after PPB, and is an accurate objective surrogate analysis for PSI quality.

No significant financial relationships to disclose.

Multi-clinical laboratory validation of a gene expression-based tissue of origin test applied to poorly differentiated and undifferentiated cancers

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Background: This multi-clinical laboratory validation assessed the accuracy, reproducibility and robustness of the Pathwork™ Tissue of Origin Test. We focused on tumor specimens that are poorly differentiated to undifferentiated (G3-G4; high grade) because this type of specimen can consume a disproportionate amount of physician time and diagnostic resources. A subset of this type of specimen ultimately will be categorized as cancer of unknown primary (CUP), which comprises 4–5% of all malignancies. The Test uses proprietary analytics and a companion genomic microarray (Pathchip™) to compare expression levels of poorly differentiated to undifferentiated specimens with 15 types of cancer. Test development involved over 2000 specimens from 14 labs, representing 15 cancers and sixty morphologies. Methods: The studies addressed operability limits, specimen stability, potential interferences and reproducibility, as well as validation in molecular diagnostics and commercial laboratories. In all, over 700 frozen tumor specimens and microarrays were analyzed. Results: Clinical validation data demonstrated that the percent agreement of the Tissue of Origin Test was 88% across all tissue types. Between-lab concordance was 95%. If the quantitative result (Similarity Score) exceeded the recommended threshold, the probability that the indicated tissue is present was 95% across all tissue types. If the Similarity Score was less than 5, the probability that the indicated tissue is absent was 98% across all tissues types. Conclusions: The Pathwork™ Tissue of Origin Test, which is under development, is accurate and highly reproducible across laboratories in this study. The test gave consistent results for different tissue handling and extraction methods and has the potential to be an effective aid in the diagnosis of cancer patients presenting with poorly differentiated and undifferentiated tumors.

No significant financial relationships to disclose.

Warfarin response and vitamin K epoxide reductase complex 1 in African Americans and Caucasians

The objective of this study was to determine whether two vitamin K epoxide reductase complex 1 (VKORC1) polymorphisms contribute to the variability in warfarin response, particularly in African Americans. The effect of the VKORC1 1173C/T and -1639G/A polymorphisms was examined in a prospective cohort study of 338 warfarin users. Subjects carrying an 1173T allele had a lower warfarin maintenance dose compared with subjects with the CC genotype in African Americans (-12.10 mg/week+/-4.93; P=0.02) and Caucasians (-14.41 mg/week+/-3.28; P<0.001). Before reaching maintenance dose, only Caucasians with the T allele had significantly increased risk of international normalized ratio >3 (odds ratio=3.10; 95% confidence interval: 1.73-5.55) compared with Caucasians with the CC genotype. Polymorphisms in the VKORC1 gene are associated with warfarin maintenance dose requirements among both African Americans and Caucasians. However, these polymorphisms may not be as useful in predicting over-anticoagulation among African Americans.

Apolipoprotein E genotype and warfarin dosing among Caucasians and African Americans

Warfarin sodium is a vitamin K antagonist that is plagued by large variability in patient response, including higher dose requirements among African Americans. Polymorphisms in the gene encoding apolipoprotein E (APOE) may partly explain this variability by altering transport of vitamin K to the liver. In a prospective cohort study of 232 individuals (52.2% Caucasian and 47.8% African American) initiating warfarin therapy, the weekly maintenance dose was significantly higher for African Americans than for Caucasians (mean 42.9 versus mean 36.9 mg, P=0.018), and the epsilon4 allele was more common among African Americans (37.8 versus 26.4% for Caucasians). In multivariable analyses, the presence of the epsilon4 allele was associated with a statistically significantly higher warfarin dose among African Americans (median 45.0 mg in epsilon4 carriers versus 35.0 mg in non-epsilon4 carriers, P=0.014) but not Caucasians (38.1 versus 35.0 mg, P=0.60). In addition, warfarin maintenance dose increased among African Americans according to genotype previously associated with differential hepatic chylomicron clearance (epsilon2/epsilon2 or epsilon2/epsilon3: 30.0 mg; epsilon3/epsilon3: 35.0 mg; epsilon3/epsilon4 or epsilon4/epsilon4: 45.0 mg; P=0.012), although the epsilon4/epsilon4 genotype was rare and not clearly associated with higher doses. The association of APOE with warfarin dosing was independent of CYP2C9 and VKORC1 polymorphisms. APOE polymorphisms thus may be important determinants of warfarin maintenance dose and could explain at least some of the observed racial differences in dose requirements.

Improving the fundamental aspects of patient care

The Welsh Assembly Government published the document Fundamentals of Care (2003) to support measures for quality improvement of care in Wales. This article reports on the progress being made in raising awareness of this framework and improving the quality of patient care in one large integrated NHS trust. The trust's steering group was instrumental in putting the guidance into action, which resulted in project development and improved practice.

Role of the JNK pathway in NMDA-mediated excitotoxicity of cortical neurons

Excitotoxic insults induce c-Jun N-terminal kinase (JNK) activation, which leads to neuronal death and contributes to many neurological conditions such as cerebral ischemia and neurodegenerative disorders. The action of JNK can be inhibited by the D-retro-inverso form of JNK inhibitor peptide (D-JNKI1), which totally prevents death induced by N-methyl-D-aspartate (NMDA) in vitro and strongly protects against different in vivo paradigms of excitotoxicity. To obtain optimal neuroprotection, it is imperative to elucidate the prosurvival action of D-JNKI1 and the death pathways that it inhibits. In cortical neuronal cultures, we first investigate the pathways by which NMDA induces JNK activation and show a rapid and selective phosphorylation of mitogen-activated protein kinase kinase 7 (MKK7), whereas the only other known JNK activator, mitogen-activated protein kinase kinase 4 (MKK4), was unaffected. We then analyze the action of D-JNKI1 on four JNK targets containing a JNK-binding domain: MAPK-activating death domain-containing protein/differentially expressed in normal and neoplastic cells (MADD/DENN), MKK7, MKK4 and JNK-interacting protein-1 (IB1/JIP-1).

Prostate brachytherapy post implant dosimetry: Timing matters

14597

Background: Permanent seed implant (PSI) brachytherapy is a common treatment modality for low-risk prostate cancer. Post implant dosimetry (PID) is utilized to asses the quality of the implant. Significant prostate swelling occurs as a result of the implant procedure, and this swelling subsides over time. PID completed on Day 0 after the implant procedure captures the prostate swelling from the procedure. Conversely, PID completed one month later does not have this swelling. PID can therefore show great variation, depending on the timing of the analysis. It is hypothesized that PID completed on Day 0 demonstrates lower dosimetric parameters than PID completed one month later. Methods: Thirteen low risk prostate cancer patients, (Stage ≤ T2, PSA < 13.9, Gleason Score ≤7) were implanted with 125Iodine seeds, with a prescription dose of 145Gy to the prostate plus a 5mm margin. Computed Tomography (CT) PID was completed for each patient on day 0 and on average 33 days following the implant. The prostate was contoured on each axial CT image and the data was analyzed using commercially available PSI planning software. The dose which encompassed 90% of the prostate volume (D90) was calculated for day 0 and day 33 PID. Results: On average, the prostate volume contoured was larger on day 0 PID (Avg. 44.9 cc; range 19–97 cc) compared to day 33 PID (Avg. 38.9 cc; range 18–59 cc) (P = 0.068). The D90 values however, were significantly higher on day 33 PID (Avg.163.7 Gy; range 125–212 Gy) than on day 0 PID (Avg.149 Gy; range 112–166 Gy) (P = 0.003). This D90 relationship was even demonstrated paradoxically in two patients whose contoured prostate volume was larger on the day 33 PID as compared to the day 0 PID. Conclusions: Timing does matter in the analysis of post implant dosimetry for PSI brachytherapy. The D90 values were significantly greater on day 33 PID compared to Day 0 PID while the contoured prostate volumes were not. Future studies which use PID planning to evaluate implant quality should specify the timing of the PID, as this would facilitate cross study comparison.

No significant financial relationships to disclose.

Patients' preference for administration of endocrine treatments by injection or tablets: results from a study of women with breast cancer

BACKGROUND

Endocrine therapies for advanced breast cancer include tablets and intramuscular injections. When treatments have similar efficacy and tolerability profiles, addressing preferences about routes of administration is important.

PATIENTS AND METHODS

Two hundred and eight women>2 years post-breast cancer diagnosis were interviewed about their preferences for daily tablets or monthly intramuscular injections. Health-care professionals treating the women estimated patients' preferences.

RESULTS

Sixty-three per cent of patients preferred tablets, 24.5% preferred the injection and 12.5% had no preference. The most cited reasons for tablet preference were convenience and dislike of needles; for injection preference, adherence and convenience. Variables associated with preferences were body mass index, educational level, attitudes towards injections and efficacy perceptions. Estimates about patients' preferences by health-care professionals varied widely. When asked to imagine scenarios where injections produced fewer hot flushes, or where two injections monthly improved efficacy, injection preference increased to 60.6% and 74.5%, respectively. Disturbingly, approximately 50% of patients admitted they sometimes forgot or chose not to take their current oral medication.

CONCLUSIONS

The majority of breast cancer patients preferred hormone therapy via daily tablets rather than monthly injections. Information about side-effects or improved efficacy altered these preferences. Adherence to treatment cannot be assumed; patients' preferences about drug administration may influence this.

C1 inhibitor deficiency: consensus document

We present a consensus document on the diagnosis and management of C1 inhibitor deficiency, a syndrome characterized clinically by recurrent episodes of angio-oedema. In hereditary angio-oedema, a rare autosomal dominant condition, C1 inhibitor function is reduced due to impaired transcription or production of non-functional protein. The diagnosis is confirmed by the presence of a low serum C4 and absent or greatly reduced C1 inhibitor level or function. The condition can cause fatal laryngeal oedema and features indistinguishable from gastrointestinal tract obstruction. Attacks can be precipitated by trauma, infection and other stimulants. Treatment is graded according to response and the clinical site of swelling. Acute treatment for severe attack is by infusion of C1 inhibitor concentrate and for minor attack attenuated androgens and/or tranexamic acid. Prophylactic treatment is by attenuated androgens and/or tranexamic acid. There are a number of new products in trial, including genetically engineered C1 esterase inhibitor, kallikrein inhibitor and bradykinin B2 receptor antagonist. Individual sections provide special advice with respect to diagnosis, management (prophylaxis and emergency care), special situations (childhood, pregnancy, contraception, travel and dental care) and service specification.

Spatial and temporal structure of edge-localized modes

This Letter provides information on the spatial and temporal structure of periodic eruptions observed in magnetically confined laboratory fusion plasmas, called edge-localized modes (ELMs), and highlights similarities with solar eruptions. Taken together, the observations presented in this Letter provide strong evidence for ELMs being associated with a filamentlike structure. These filaments are extended along a field line, are generated on a 100 micros time scale, erupt from the outboard side, and connect back into the plasma. Such structures are predicted by a theoretical model based on the "ballooning" instability, developed for both solar and tokamak applications.

Protecting the terminus: t-loops and telomere end-binding proteins

Telomeric DNA is composed of a region of duplex telomeric tract followed by a single-strand overhang on the 3' G-rich strand. The DNA is packaged by proteins that associate directly with the single- and double-strand regions of the telomeric tract and by their associated proteins. This review discusses the evidence that G-strand overhangs are present on both ends of eukaryotic chromosomes and the steps needed to generate these overhangs. The overhangs are protected by specialized G-overhang-binding protein and/or invasion by the overhang of the duplex region of the telomeric tract to form a structure called a 't-loop'. The G-overhang-binding proteins identified from different species are described, and their properties compared. The data supporting the existence of t-loops at native telomeres is discussed, and the conditions required to promote their in vitro formation are presented.

A Markov model of treatment of newly diagnosed epilepsy in the UK. An initial assessment of cost-effectiveness of topiramate

Long-term comparative trials among newer antiepileptic drugs are lacking; therefore decision models are needed to guide treatment decisions. The goal of this study was to develop an economic model of newly diagnosed epilepsy in the UK and to provide the first assessment of topiramate. A Markov model was developed combining data from clinical trials, cost-of illness, mortality, and utility studies. Expected costs and utilities associated with treatment strategies (first- and second-line treatments) were compared to find the cost-effectiveness frontier. First- and second-line monotherapy with topiramate or carbamazepine in partial seizures was less costly and more effective than other scenarios. In generalised seizures first-line topiramate was cost-effective with valproate or lamotrigine as second-line treatments depending on the set of utilities used. Models provide a relevant framework within which costs and health gains of antiepileptic drugs treatment options can be studied. Our findings are further evidence of the promising role of topiramate for patients with newly diagnosed epilepsy.

Attitudes to Prophylactic Surgery and Chemoprevention in Australian Women at Increased Risk for Breast Cancer

BACKGROUND

Because of the uncertain efficacy of breast cancer screening in women at increased risk of developing breast cancer, bilateral prophylactic oophorectomy and mastectomy are considered management options for high-risk women. Data on the attitudes to prophylactic strategies of high-risk women who have not attended specialist clinics are needed to ascertain the need for patient education and provide the basis for planning of support services.

METHODS

Three hundred seventy-one women unaffected by cancer and with unknown mutation status from families with a dominantly inherited susceptibility to breast cancer, recruited through a large Australian population-based, epidemiological study, were assessed using a mailed self-administered questionnaire with validated measures of psychological outcome.

RESULTS

Sixteen percent of women reported considering prophylactic mastectomy, and 1% had already had the procedure. Among women with a family history of breast/ovarian cancer, 33% had considered and 5% had already had a prophylactic oophorectomy. Twenty-three percent of women reported considering taking tamoxifen if it were shown to prevent breast cancer. Consideration of prophylactic oophorectomy (OR = 1.51 for a 10% change in perceived risk, 95% CI 1.14-1.99, p = 0.0045) and tamoxifen (OR = 1.14 for a 10% change in perceived risk, 95% CI 1.002-1.30, p = 0.047) were positively associated with perceived cancer risk.

CONCLUSIONS

Attitudes to prophylactic surgery and psychological distress levels in high-risk women participating in an epidemiological study appear to be comparable to those of women attending familial cancer clinics and indicate that women attending high-risk clinics may be representative of the larger population of women at increased risk.

Extended formulary nurse prescribing--another saliva substitute roadblock

United Kingdom family physicians, General Practitioners (GPs), are allowed to prescribe from a Department of Health-approved list of non-medicines (the 'ACBS' list) which includes a majority of proprietary saliva substitutes. Independent nurse prescribing, introduced in 2001, has improved patient access to effective remedies for a wide range of common medical problems. Further qualified 'extended formulary nurse prescribers' have access to a limited range of prescription medicines, and all non-prescription medicines that GPs may currently prescribe. Despite their specified role in the management of oral complications encountered in palliative care, a similar anomaly in NHS rules that prevents dental practitioners from prescribing ACBS listed saliva substitutes also prevents nurses from prescribing them. Sadly, patients are suffering poorer access to simple and effective remedies to conditions such as xerostomia - a condition that has recognised impact on their quality of life.

Measuring costs and consequences in economic evaluation in asthma

Formal economic evaluation is playing an increasingly important role in health-care decision-making. This is shown by the requirement to present economic data to support applications for public reimbursement for new pharmaceuticals in Australia and the provinces of Canada, and by the appraisal process initiated by the National Institute for Clinical Excellence in the U.K. This growing role of economic analysis applies as much to the field of asthma as anywhere. This paper provides a detailed review of applied economic studies in asthma. The review is used to explore a range of methodological issues in the field including the choice of perspective and maximand, whether to use disease-specific or generic measures of outcome and whether decision-makers should receive disaggregated cost and consequence data or results that focus on an incremental cost-effectiveness ratio. It is concluded that, given the heterogeneity in decision-makers' objectives and constraints, economic studies should be planned and executed in such a way as to maximize flexibility in how results are presented.

Use of videotape to assess mobility in a controlled randomized crossover trial of physiotherapy in chronic multiple sclerosis

OBJECTIVES

To determine to what degree assessment of mobility based on comparison of videotape recordings before and after courses of physiotherapy in patients with chronic multiple sclerosis (MS) is reliable, correlates with 'live' assessments and indicates benefit.

DESIGN

Prospective data collection within a randomized crossover controlled trial of physiotherapy at home, as an outpatient, or 'no therapy' in 40 patients.

SETTING

Hospital outpatients: outpatient and home physiotherapy.

OUTCOMES

Mobility change based on a comparison of short video recordings before and after each treatment period was scored independently by two physiotherapists blinded to therapy type and other measures of outcome. Scores were compared with changes in the Rivermead Mobility Index (RMI) and other indices assessed by a physiotherapist in the patient's home.

RESULTS

The two video observers agreed substantially on patient outcome. Changes in walking based on video correlated with RMI for home treatment (r = 0.41, p = 0.008) but not for hospital or no treatment periods (r = 0.14 and 0.15): video changes correlated with the 'live' assessor's global change score inconsistently ('no therapy' r = 0.48, p = 0.002, hospital r = 0.30, p = 0.06 and home r = 0.17, p = 0.30 treatment periods). Based on video data alone, improved mobility was evident following home therapy for only one observer but not for the other or the averaged scores of both.

CONCLUSION

There was substantial agreement between two observers deciding on change in mobility based on independent blinded evaluation of short video sequences. However the correlations of these with 'live' assessments were variable. Physiotherapy had a less clear benefit on mobility based on video analysis alone compared with 'live' assessments. The study highlights the need for more objective measures of habitual mobility over longer periods.

Xenoendocrine disrupters-tiered screening and testing: filling key data gaps

The US Environmental Protection Agency (EPA) is developing a screening and testing program for endocrine disrupting chemicals (EDCs) to detect alterations of hypothalamic-pituitary-gonadal (HPG) function, estrogen (ER), androgen (AR) and thyroid hormone synthesis and AR and ER receptor-mediated effects in mammals and other animals. High priority chemicals would be evaluated in the Tier 1 Screening (T1S) battery and chemicals positive in T1S would then be tested (Tier 2). T1S includes in vitro ER and AR receptor binding and/or gene expression, an assessment of steroidogenesis and mammalian (rat) and nonmammalian in vivo assays (Table 1). In vivo, the uterotropic assay detects estrogens and antiestrogens, while steroidogenesis, antithyroid activity, (anti)estrogenicity and HPG function are assessed in a 'Pubertal Female Assay'. (Anti-) androgens are detected in the Hershberger Assay (weight of AR-dependent tissues in castrate-immature-male rats). Fish and amphibian assays also are being developed. The fathead minnow assay can identify EDCs displaying several mechanisms of concern, including AR and ER receptor agonists and antagonists and inhibitors of steroid hormone synthesis. An amphibian metamorphosis assay is being developed to detect thyroid-active substances. Several alternative mammalian in vivo assays have been proposed. Of these, a short-term pubertal male rat assay appears most promising. An in utero-lactational screening protocol also is being evaluated. For Tier 2, the numbers of endocrine sensitive endpoints and offspring (F1) examined in multigenerational tests need to be expanded for EDCs. Consideration should be given to tailoring T2, based on the results of T1S. Tier 1 and 2 also should examine relevant mixtures of EDCs. Toxicants that induce malformations in AR-dependent tissues produce cumulative effects even when two chemicals act via different mechanisms of action.

How many years do students study before graduating in medicine?

OBJECTIVES

The Faculty of Health Sciences at the University of the Witwatersrand is considering changing from a 6-year medical degree to a mainly graduate-entry 4-year degree. The objective of this study was to determine how long students currently take to qualify and how many years are spent studying for each medical graduate produced.

DESIGN

A retrospective study of 691 students registered in medicine at the University of the Witwatersrand in 1988, 1989 and 1990 was conducted by examining student progress records.

RESULTS

The study found that an average of 7.89 years was spent studying for each graduate produced, including tertiary studies before medicine, repeated years and intercalated science degrees. Five hundred and eighty-nine students (85%) graduated and 102 (15%) did not. Forty-eight per cent studied for 7 or more years before graduating, 21% completed degrees before or during their medical studies, and 21% of students repeated years.

CONCLUSION

The costs to the individual and society of the new 3 + 4-year degree structure would not be very different from those of the current 6-year structure.

Who needs sustainability?

Three inescapable factors face us at the turn of the century. First, the climate, and with it the supply of water, is becoming more variable. Regardless of whether this variability is the result of man-made global warming, it seems to be with us. Secondly, demand for water will increase; in many countries domestic water use is currently less than 25 1/personday and needs to increase if living conditions are to improve. In Great Britain, per capita use of water is low compared with many other western countries — including those that pay for water on a metered basis — and it is certain to rise as living standards improve. Thirdly, concern for the environment is likely to increase. We can counter the first problem only by ensuring that we have adequate water storage; most water storage in Great Britain and the rest of the world is in the ground. We need to counter the second by recognizing that the vast majority of public water use is non-consumptive, but that very little waste water is re-used efficiently. We need to counter the third by welcoming the concern but ensuring that the response is sensible. We must be prepared to question some of the accepted wisdom of the environmental movement, and remember that many of the developments in human history were non-sustainable. Do they represent environmental disasters, or human progress?

Budget impact model for determining the costs of introducing inhaled salmeterol/fluticasone propionate combination for the management of persistent asthma in France

A budget impact model was used to estimate the effect of introducing inhaled salmeterol/fluticasone propionate combination on asthma drug-related costs in France. The model is based on disease prevalence, drug use, drug acquisition cost and sales forecasting data specific to France. It takes the perspective of social security and has a time horizon of 1 year. All drug acquisition costs are adjusted for the average rate of reimbursement of asthma medications in France (77.3%). All costs are expressed in euros. The model shows that if patients receiving concurrent salmeterol plus fluticasone propionate (or budesonide plus formoterol switch to combined salmeterol/fluticasone propionate, the anticipated annual savings would be 2,691,580 and 1,916,966 euros, respectively. On a fixed budget 4067 additional patients could be treated if salmeterol/fluticasone propionate is substituted for concurrent salmeterol plus fluticasone propionate and an additional 2939 patients if the combination is used to replace concurrent budesonide plus formoterol. Overall, using sales forecasting data to estimate how many patients will switch to the new combination from their current therapy, it is estimated that the introduction of salmeterol/fluticasone propionate will increase the national expenditure in France on asthma medications by a maximum of 3%. This budget impact model shows that the introduction of inhaled salmeterol/fluticasone propionate combination is likely to have minimal impact on asthma-related medication costs in France. Moreover, the available data on the salmeterol/fluticasone propionate combination suggest that it is clinically effective, cost-effective and affordable to the French healthcare system.

Questionnaire survey of the views of the delegates at the European Cervical Spine Research Society meeting on the administration of methylprednisolone for acute traumatic spinal cord injury

STUDY DESIGN

A questionnaire survey.

OBJECTIVES

To collate and analyze the views of the delegates who attended the European Cervical Spine Research Society (CSRS) meeting on the use of methylprednisolone for acute traumatic spinal cord injury.

SUMMARY OF BACKGROUND DATA

The NASCIS II and III studies reported improved neurologic recovery in patients who were treated with methylprednisolone within 8 hours of their acute traumatic spinal cord injury. A number of reported commentaries have criticized these trials. A recent audit in the authors' regional spinal injuries unit in the United Kingdom found that a large percentage of patients were not receiving methylprednisolone. The authors decided to collate the views of the delegates at the CSRS regarding the use of steroids for acute traumatic spinal cord injury.

METHODOLOGY

A questionnaire was created that took into account the positive reported findings as well as the criticisms of the NASCIS studies. Delegates who attended the European CSRS meeting completed this questionnaire.

RESULTS

Seventy-five percent of the delegates answered that they used or recommended methylprednisolone in the treatment of acute traumatic spinal cord injury. Nevertheless, the delegates had an average of 1.5 reservations about administering methylprednisolone. The most common reservation was that they did not think the improvement conferred to the patients by administering methylprednisolone had been clinically or functionally proven. There were reservations about the validity of the statistical analysis used in the NASCIS studies and by the omission of a placebo group in NASCIS III. The majority of the delegates thought it was not medicolegally negligent to withhold the administration of methylprednisolone in the treatment of acute traumatic spinal cord injury.

CONCLUSION

The use of methylprednisolone in the treatment of acute traumatic spinal cord injury is still controversial. It would appear from a recent prospective audit at the authors' spinal injuries unit that a large percentage of patients in the United Kingdom are not receiving methylprednisolone. Because so much doubt exists, the NASCIS studies should be repeated.

MHC class II proteins contain a potential binding site for the verotoxin receptor glycolipid CD77

Globotriaosyl ceramide or CD77 functions as a cell surface receptor for toxins of the Shiga toxin/verotoxin family and as a marker for germinal center stage B-cells. The B-cell protein CD19 and the interferon-alpha receptor possess verotoxin-like amino acid sequences in their extracellular domains, and CD77 has been shown to function in CD19-mediated adhesion and interferon-induced growth inhibition. The Burkitt's lymphoma cell line, Daudi, is similar to germinal center B-cells in their expression of CD77, CD19 and MHC class II molecules. Using the multiple sequence alignment program, ClustalW, we have identified a verotoxin-like amino acid sequence on the beta-chain of human and murine MHC class II molecules. Binding of CD77 at this site could modulate the peptide-binding properties of these MHC class II molecules. Using Western blot analysis of whole cell extracts, we found that CD77-positive Daudi cells have higher levels of HLA-D proteins than VT500 cells, a Daudi-derived CD77-deficient mutant cell line. In contrast, MHC class II-mediated adhesion and surface expression are similar in the two cell lines. Therefore, CD77 could play a functional or regulatory role in MHC class II-mediated functions specifically relating to antigen presentation by B-cells to T helper cells.