Effect of very early intravenous streptokinase infusion in patients with evolving myocardial infarction

The effect of very early infusion of 1.5 X 10(6) U of streptokinase intravenously was studied in 29 patients with nitroglycerin-resistant chest pain and ST-segment elevation. Infarct size was estimated from maximal LD1 isoenzyme levels, and the diagnosis confirmed by CK-MB determination. Thrombolytic therapy was started within 1 hour of pain onset in 11 patients (group A), between 1 and 2 hours in 10 (group B), and later than 2 hours in eight patients (group C). Marked differences appeared between the groups. Thus, three patients in group A and one patient in group B did not develop infarction, all had critical LAD stenoses. Three patients in group C died in shock without bleeding. Further, the average maximal LD1 values in the 22 patients who survived their infarction differed significantly between the groups, and were 12.6, 19.1 and 36.2 mu kat/l in groups A, B and C, respectively. In conclusion, very early intravenous streptokinase infusion probably reduces myocardial necrosis, and possible prevents infarction in some patients.

Antihypertensive, haemodynamic and metabolic effects of nifedipine slow-release tablets in elderly patients

In a double-blind, cross-over study for 8 weeks, including 10 non-hospitalized elderly hypertensives (average age 73.2 years), WHO stage I-II, the antihypertensive effect of nifedipine slow-release tablets, 20 mg twice daily, was compared with placebo. Nifedipine reduced supine and standing blood pressure values significantly, and no signs of orthostatic hypotension were noted. An initial increment in heart rate was found after 1 week with a subsequent fall towards control values after 8 weeks of nifedipine administration. Heart rate pressure product in the supine position was reduced, and this reduction became statistically significant at the 8th week. Cardiac output measured non-invasively in 8 patients after 6-8 weeks' nifedipine therapy, using an Irex echocardiograph, was on an average 34% higher than in the placebo period (p less than 0.05). Serum electrolytes, cholesterol, HDL cholesterol, blood glucose and renal function were not affected by the drug. Side-effects were few and mild. It is concluded that nifedipine is a potent antihypertensive agent which may represent an attractive first choice alternative in the treatment of elderly hypertensive patients.

Determination of the EC50 of levobupivacaine for femoral and sciatic perineural infusion after total knee arthroplasty

BACKGROUND

Infusion of local anaesthetic through femoral and sciatic catheters is an accepted method of providing pain relief after knee arthroplasty. However, the minimum effective concentration of perineural local anaesthetics is not known.

METHODS

Twenty-four patients received femoral and sciatic perineural infusions of levobupivacaine in order to prevent pain relief after total knee arthroplasty. The primary endpoint of the study was patient request for analgesic rescue for anterior or posterior knee pain within the first 36 h of perineural infusion. Treatment was determined by the method of sequential allocation, with a dosing interval of 0.002% w/v.

RESULTS

Thirteen patients did not require rescue analgesia for anterior knee pain and 16 patients did not require rescue analgesia for posterior knee pain. Median duration of failed blocks until rescue analgesia was 25 h (24-27 h) for the femoral block and 27 h (24-29 h) for the sciatic block. The minimum concentration at which patients did not require rescue analgesia was 0.024% for the femoral nerve and 0.014% for the sciatic nerve. Comparison of EC(50) showed that local anaesthetic requirements were significantly (P=0.03) higher by a factor of 1.25 (95% CI 1.03-1.55) for the femoral compared with the sciatic nerve.

CONCLUSIONS

The EC(50) for femoral perineural infusion is greater than the EC(50) for sciatic perineural infusion.

Signaling individual identity versus quality: a model and case studies with ruffs, queleas, and house finches

We develop an evolutionary model that predicts that characters selected to signal individual identity will have properties differing from those expected for indicator signals of quality. Traits signaling identity should be highly variable, often display polymodal distributions, not be condition dependent (i.e., be cheap to produce and/or maintain), not be associated with fitness differences, exhibit independent assortment of component characters, and often occur as fixed phenotypes with a high degree of genetic determination. We illustrate the existence of traits with precisely these attributes in the ornamental, conspicuously variable, and sexually dimorphic breeding plumages of ruff sandpipers Philomachus pugnax and red-billed queleas Quelea quelea. Although ruffs lek and queleas are monogamous, both species breed in high-density aggregations with high rates of social interactions (e.g., aggression and territory defense). Under these socioecological conditions, individual recognition based on visual cues may be unusually important. In contrast to these species, we also review plumage characteristics in house finches Carpodacus mexicanus, a nonterritorial, dispersed-breeding species in which plumage ornamentation is thought to signal quality. In keeping with expectations for quality signals, house finch plumage is relatively less variable, unimodally distributed, condition dependent, correlated with fitness measures, has positively correlated component characters, and is a plastic, environmentally determined trait. We briefly discuss signals of identity in other animals.

Effects of the Diabetes Manual 1:1 structured education in primary care

AIMS

To determine the effects of the Diabetes Manual on glycaemic control, diabetes-related distress and confidence to self-care of patients with Type 2 diabetes.

METHODS

A cluster randomized, controlled trial of an intervention group vs. a 6-month delayed-intervention control group with a nested qualitative study. Participants were 48 urban general practices in the West Midlands, UK, with high population deprivation levels and 245 adults with Type 2 diabetes with a mean age of 62 years recruited pre-randomization. The Diabetes Manual is 1:1 structured education designed for delivery by practice nurses. Measured outcomes were HbA(1c), cardiovascular risk factors, diabetes-related distress measured by the Problem Areas in Diabetes Scale and confidence to self-care measured by the Diabetes Management Self-Efficacy Scale. Outcomes were assessed at baseline and 26 weeks.

RESULTS

There was no significant difference in HbA(1c) between the intervention group and the control group [difference -0.08%, 95% confidence interval (CI) -0.28, 0.11]. Diabetes-related distress scores were lower in the intervention group compared with the control group (difference -4.5, 95% CI -8.1, -1.0). Confidence to self-care Scores were 11.2 points higher (95% CI 4.4, 18.0) in the intervention group compared with the control group. The patient response rate was 18.5%.

CONCLUSIONS

In this population, the Diabetes Manual achieved a small improvement in patient diabetes-related distress and confidence to self-care over 26 weeks, without a change in glycaemic control. Further study is needed to optimize the intervention and characterize those for whom it is more clinically and psychologically effective to support its use in primary care.

Development and validation of the Diabetes Obstacles Questionnaire (DOQ) to assess obstacles in living with Type 2 diabetes

AIMS

To develop and validate an easy-to-use questionnaire to identify obstacles to self management in Type 2 diabetes.

METHODS

The Diabetes Obstacles Questionnaire (DOQ) was developed from earlier research and the literature. It was completed by 180 people with Type 2 diabetes, recruited from 22 general practices in the UK. Responders also completed a quality-of-life questionnaire (ADDQoL) and the Problem Areas in Diabetes (PAID) scale.

RESULTS

From analysis of the 176 usable questionnaires, 36 items of the original 113 items were deemed redundant. The remaining 77 items were assembled into eight sub-scales covering Medication, Self Monitoring, Knowledge and Beliefs, Diagnosis, Relationships with Health-Care Professionals, Lifestyle Changes, Coping, and Advice and Support. Each sub-scale had a factor structure of no more than three factors, had Cronbach's alpha of more than 0.75, and a Kaiser-Meyer-Olkin of more than 0.75. Each sub-scale correlated significantly with the PAID scale (P < 0.01), demonstrating criterion validity. Construct validity was shown by significant correlation between HbA(1c) and the sub-scales which relate to managing blood glucose levels: Self Monitoring, Relationship with Health-Care Professionals, Lifestyle Changes and Coping. Construct validity was further shown by significant correlation between QoL scores and Medication, Lifestyle Changes and Coping.

DISCUSSION

The DOQ, comprising eight sub-scales, is a usable, valid instrument for both clinical and research settings. It helps to identify in detail the obstacles which an individual finds in living with Type 2 diabetes.

Advances in molecular classification of renal neoplasms

Kidney neoplasms are classified by light microscopy using the World Health Organization (WHO) system. The WHO system defines histopathologic tumor subtypes with distinct clinical behavior and underlying genetic mutations. In adults, the common malignant subtypes are variants of renal cell carcinoma (RCC). Histopathologic classification is critical for clinical management of RCC, but is becoming more complex with recognition of novel tumor subtypes, development of procedures yielding small diagnostic biopsies, and emergence of molecular therapies directed at tumor gene activity. Therefore, classification systems based on gene expression are likely to become essential for diagnosis, prognosis and treatment of kidney tumors. Recent DNA microarray studies have shown that clinically relevant renal tumor subtypes are characterized by distinct gene expression profiles, which are useful for discovery of novel diagnostic and prognostic biomarkers. In this review, we summarize the WHO classification system for renal tumors, general applications of microarray technology in cancer research, and specific microarray studies that have advanced knowledge of renal tumor diagnosis, prognosis, therapy and pathobiology.

The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review

Depression is common in cancer patients, and this often remains undetected and untreated. Depression has been associated with poorer quality of life, in addition to increased impairment of immune response and poorer survival in cancer patients. Previous systematic reviews and meta-analyses of the efficacy of interventions for cancer patients with depression have failed to distinguish between caseness for depression and depressive symptoms. The findings from this systematic review show that there is limited trial data on the efficacy of prescribed antidepressants in reducing the incidence of major depression and depressive symptoms in cancer patients. Contrary to previous reviews that failed to distinguish between depressive symptoms and depression, this review found very little data from clinical trials (without the possibility of confounding factors) to demonstrate that psychotherapeutic interventions are effective in reducing depression in cancer patients. A number of small-scale, single-centre trials indicated that psychotherapeutic interventions (especially cognitive behavioural therapy) can have effects on depressive symptoms in cancer patients. However, given the methodological limitations of studies to date, lack of evidence should not be interpreted as implying lack of efficacy. In conclusion, there is a need for adequately powered studies of pharmacological and psychotherapeutic studies, which are targeted at cancer patients with a diagnosis of depression and include monitoring of the use of other pharmacological/psychotherapeutic and complementary and alternative medicine interventions.

Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs

AIM

To describe emergency ambulance crews' views about (1) how they make decisions on whether to convey patients to hospital; (2) an intervention enabling them to triage patients to non-conveyance; and (3) their experience of using new protocols for undertaking such triage.

METHODS

Two focus groups were held at the outset of an evaluation of Treat and Refer (T&R) protocols: one with staff based at an ambulance station who were to implement the new service (intervention station), and the other with staff from a neighbouring station who would be continuing their normal practice during the study (control station). A third session was held with staff from the intervention station following training and 3 months' experience of protocol usage.

RESULTS

Before the introduction of the T&R protocols, crews reported experience, intuition, training, time of call during shift, patient preference, and home situation as influencing their decisions concerning conveyance. Crews were positive about changing practice but foresaw difficulties with advising patients who wanted to go to hospital, and with referral to other agencies. Following experience of T&R protocol use, crews felt they had needed more training than had been provided. Some felt their practice and job satisfaction had improved. Problems with referral and with persuading some patients that they did not need to go to hospital were discussed. There was consensus that the initiative should be introduced across the service.

CONCLUSIONS

With crews generally positive about this intervention, an opportunity to tackle this difficult area of emergency care now exists. This study has, however, highlighted the complexity of the change in practice and service delivery, and professional and organisational constraints that need to be considered.

Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews

OBJECTIVE

To develop and evaluate "Treat and Refer" protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate.

METHODS

Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire.

RESULTS

Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided.

CONCLUSIONS

"Treat and Refer" protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews

OBJECTIVE

To develop and evaluate "Treat and Refer" protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate.

METHODS

Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire.

RESULTS

Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided.

CONCLUSIONS

"Treat and Refer" protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

308. Characterization of SIV infection in the male genital tract of juvenile macaques

Reproductive organs contribute infected cells and free viral particles to semen in human immunodeficiency type-1 (HIV-1) infected individuals, increasing the risk of infection from the HIV-1 positive male to the mother and ultimately to the offspring. The majority of information gathered with respect to the HIV-1 burden in the male reproductive tract (MGT) have been conducted in tissues obtained on autopsies of testis, prostate and epididymis of individuals that die from AIDS. Therefore, little is known about the progression and pathogenesis of the infection within these organs. Investigating the mechanism of the spread of HIV-1 in the cells and tissues of the MGT, particularly during the asymptomatic stage, remains a critical task. Infection of macaques with simian immunodeficiency virus (SIV) is a useful animal model for studies of mucosal transmission and viral transmission via breastfeeding. In this study eight juvenile macaques (2.5 yo) were infected with SIVmac for a period of 3–6 months and testis and epididymis tissue were collected in two intervals, 3 and 6 months post-infection. To determine SIV progression and pathogenesis in the MGT we have used EM, immunohistochemistry, confocal microscopy and immunoblotting. Our preliminary EM obtained via analysis of testis and epididymis tissue of SIV infected macaques show the presence of elongated spermatids in the epididymis. Scattered viral like SIV particles were observed in the testis and epididymal lumen, principally associated with aberrant germ cells. Necrosis of epididymal tissue was also observed, potentially due to the SIV burden in this organ. The data indicate that SIV infected juvenile macaques are a potential model for studying HIV-1 pathogenesis and its effect in spermatogenesis as well as the immune response of testis in a species that is closely related to humans.

Safety of telephone consultation for "non-serious" emergency ambulance service patients

OBJECTIVE

To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls).

DESIGN

Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority dispatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that dispatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted.

SETTING

Ambulance services in London and the West Midlands, UK.

STUDY POPULATION

Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified.

MAIN OUTCOME MEASURES

Assessment of safety of triage decisions.

RESULTS

Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately dispatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system.

CONCLUSIONS

Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

Safety of telephone consultation for "non-serious" emergency ambulance service patients

OBJECTIVE

To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls).

DESIGN

Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority dispatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that dispatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted.

SETTING

Ambulance services in London and the West Midlands, UK.

STUDY POPULATION

Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified.

MAIN OUTCOME MEASURES

Assessment of safety of triage decisions.

RESULTS

Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately dispatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system.

CONCLUSIONS

Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

A survey of current consultant practice of treatment of severe ankle sprains in emergency departments in the United Kingdom

OBJECTIVE

To determine current consultant practice in larger UK emergency departments in the management of severe ankle sprains.

DESIGN

Questionnaire study to all UK emergency departments seeing more than 50 000 new patients per year.

RESULTS

70% response rate. Most popular treatment was ice, elevation, Tubigrip, and exercise, each of which was reported as used in most cases by over 70% of respondents. Crutches, early weight bearing, and non-steroidal anti-inflammatory drugs were each reported as used in most cases at over half of responding departments. Physiotherapy was usually only used in selected cases. Rest was usually advised for one to three days (35%). Follow up was only recommended for selected patients.

CONCLUSIONS

The results of this survey suggest that there is considerable variation in some aspects of the clinical approach (including drug treatment, walking aids, periods of rest) taken to the management of severe ankle sprains in the UK, although in some areas (for example, not routinely immobilising, early weight bearing as pain permits, use of physiotherapy, use of rest, ice, and elevation) there was concordance.

Attitudes of GPs towards the provision of acupuncture on the NHS

OBJECTIVE

To investigate the attitudes of General Practitioners (GPs) to acupuncture, whether they think it should be available on the NHS and, if so, how it should be provided.

DESIGN

Attitudinal postal survey.

SETTING

All 65 practising GPs in the 12 GP practices of the Melton Rutland & Harborough Primary Care Group, UK.

RESULTS

A response rate of 83% was achieved. The main findings show that 59% of GPs agreed that acupuncture should be available on the NHS, 83% agreed that it can be clinically useful and 72% that it can be cost effective. Among GPs who acknowledged the potential for an increased role for acupuncture on the NHS there was support for the provision of treatment from either medical or non-medical practitioners, delivered at either NHS or non-NHS premises, and with the NHS providing some, or all, of the required funding.

CONCLUSION

The findings suggest that a majority of GPs are in favour of acupuncture being more widely available on the NHS.

Computer assisted assessment and advice for "non-serious" 999 ambulance service callers: the potential impact on ambulance despatch

OBJECTIVE

To investigate the potential impact for ambulance services of telephone assessment and triage for callers who present with non-serious problems (Category C calls) as classified by ambulance service call takers.

DESIGN

Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch.

SETTING

Ambulance services in London and the West Midlands.

SUBJECTS

Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300.

MAIN OUTCOME MEASURES

Triage decision, ambulance cancellation, attendance at an emergency department.

RESULTS

In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47).

CONCLUSIONS

The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation.

Tissue-culture enhanced transposition of the maize transposable element Dissociation in Brassica oleracea var. ' Italica'

To investigate the potential of heterologous transposons as a gene tagging system in broccoli ( Brassica oleracea var. Italica), we have introduced a Ds-based two-element transposon system. Ds has been cloned into a 35S-SPT excision-marker system, with transposition being driven by an independent 35S-transposase gene construct ( Tpase). In three successive selfed generations of plants there was no evidence of germinal-excision events. To overcome this apparent inability to produce B. oleracea plants with germinal excisions, we performed a novel tissue-culture technique to select for fully green shoots from seed with somatic-excision events. The results showed a very high efficiency of regeneration of fully green plants (up to 65%) and molecular analysis indicated that the plants genetically were like plants that contain a germinal-excision event. Further molecular analysis of these plants showed that 69% exhibited reinsertion of Ds back into the plant genome. Sequencing of donor-site footprints after Ds excision, revealed that there is an indication of more-severe deletions and rearrangements when higher concentrations of streptomycin are used in the tissue-culture selection process. Adapted versions of this regeneration technique have a high potential for providing germinal excision-like events in heterologous plants species which show low transposon activity. Alternatively, there is the potential to increase the proportion of 'germinal' plants in earlier generations of more-active plant species.

A qualitative study of older people's views of out-of-hours services

BACKGROUND

Out-of-hours primary care services continues to change with the growth of general practitioner (GP) co-operatives and the more recent development of NHS Direct. While older people are more likely to have increased needs for such services, evidence suggests that they are reluctant users of GP out-of-hours services.

AIM

To explore older people's experiences and perceptions of different models of general practice out-of-hours services.

DESIGN OF STUDY

Focus group methodology, with qualitative data analysis undertaken using a grounded theory (Framework) approach.

SETTING

Thirty people aged between 65 and 81 years old from community groups based in south east London.

METHOD

Four focus groups were held, each with between five and 12 participants. Each focus group session lasted 90 minutes and was audiotape-recorded with the permission of the participants. The tapes were transcribed verbatim.

RESULTS

Two related themes were identified. First, attitudes to health and healthcare professionals with reference to the use of health services prior to the establishment of the NHS, a stoical attitude towards health, and not wanting to make excessive demands on health services. Second, the experience of out-of-hours care and the perceived barriers to its use, including the use of the telephone and travelling at night. Participants preferred contact with a familiar doctor and were distrustful of telephone advice, particularly from nurses.

CONCLUSIONS

Older people appear reluctant to make use of out-of-hours services and are critical of the trend away from out-of-hours care being delivered by a familiar GP. With increasing numbers of older people in the population it is important to consider steps to address their reluctance to use out-of-hours and telephone advice services, particularly those based around less personal models of care.

Weight gain following treatment of hyperthyroidism

OBJECTIVE

Patients frequently express concern that treating hyperthyroidism will lead to excessive weight gain. This study aimed to determine the extent of, and risk factors for, weight gain in an unselected group of hyperthyroid patients.

DESIGN AND SUBJECTS

We investigated 162 consecutive hyperthyroid patients followed for at least 6 months. Height, weight, clinical features, biochemistry and management were recorded at each clinic visit.

RESULTS

Documented weight gain was 5.42 +/- 0.46 kg (mean +/- SE) and increase in BMI was 8.49 +/- 0.71%, over a mean 24.2 +/- 1.6 months. Pre-existing obesity, Graves' disease causing hyperthyroidism, weight loss before presentation and length of follow-up each independently predicted weight gain. Patients treated with thionamides or radioiodine gained a similar amount of weight (thionamides, n = 87, 5.16 +/- 0.63 kg vs. radioiodine, n = 62, 4.75 +/- 0.57 kg, P = 0.645), but patients who underwent thyroidectomy (n = 13) gained more weight (10.27 +/- 2.56 kg vs. others, P = 0.007). Development of hypothyroidism (even transiently) was associated with weight gain (never hypothyroid, n = 102, 4.57 +/- 0.52 kg, transiently hypothyroid, n = 29, 5.37 +/- 0.85 kg, on T4, n = 31, 8.06 +/- 1.42 kg, P = 0.014). This difference remained after correcting for length of follow-up. In the whole cohort, weight increased by 3.95 +/- 0.40 kg at 1 year (n = 144) to 9.91 +/- 1.62 kg after 4 years (n = 27) (P = 0.008), representing a mean weight gain of 3.66 +/- 0.44 kg/year.

CONCLUSION

We have demonstrated marked weight gain after treatment of hyperthyroidism. Pre-existing obesity, a diagnosis of Graves' disease and prior weight loss independently predicted weight gain and weight continued to rise with time. Patients who became hypothyroid, despite T4 replacement, gained most weight.

What is chronic fatigue syndrome? Heterogeneity within an international multicentre study

OBJECTIVE

We sought to compare the characteristics of patients presenting with chronic fatigue (CF) and related syndromes in eight international centres and to subclassify these subjects based on symptom profiles. The validity of the subclasses was then tested against clinical data.

METHOD

Subjects with a clinical diagnosis of CF completed a 119-item self-report questionnaire to provide clinical symptom data and other information such as illness course and functional impairment. Subclasses were generated using a principal components-like analysis followed by latent profile analysis (LPA).

RESULTS

744 subjects returned complete data sets (mean age 40.8 years, mean length of illness 7.9 years, female to male ratio 3:1). Overall, the subjects had a high rate of reporting typical CF symptoms (fatigue, neuropsychological dysfunction, sleep disturbance). Using LPA, two subclasses were generated. Class one (68% sample) was characterized by: younger age, lower female to male ratio; shorter episode duration; less premorbid, current and familial psychiatric morbidity; and, less functional disability. Class two subjects (32%) had features more consistent with a somatoform illness. There was substantial variation in subclass prevalences between the study centres (Class two range 6-48%).

CONCLUSIONS

Criteria-based approaches to the diagnosis of CF and related syndromes do not select a homogeneous patient group. While substratification of patients is essential for further aetiological and treatment research, the basis for allocating such subcategories remains controversial.