Perceptions of physician order entry: results of a cross-site qualitative study

OBJECTIVE

To identify perspectives of success factors for implementing computerized physician order entry (POE) in the inpatient setting.

DESIGN

Qualitative study by a multidisciplinary team using data from observation, focus groups, and both formal and informal interviews. Data were analyzed using a grounded approach to develop a taxonomy of patterns and themes from the transcripts and field notes.

RESULTS

A taxonomy of ten high level themes was developed, including 1) separating POE from other processes, 2) terms, concepts, and connotations, 3) context, 4) tradeoffs, 5) conflicts and contradictions, 6) collaboration and trust, 7) leaders and bridgers, 8) the organization of information, 9) the ongoing nature of implementation, and 10) temporal concerns.

CONCLUSION

The identified success factors indicate that POE implementation is an iterative and difficult process, but informants perceive it is worth the effort.

Investigating physician order entry in the field: lessons learned in a multi-center study

The progress of studies by this team of researchers concerning computerized physician order entry (POE), beginning with a mail survey and moving to qualitative multi-center studies, is reviewed, with emphases on lessons learned and future directions. While mail surveys were appropriate to answer initial research questions about diffusion of POE in the U.S., multiple qualitative methods became the methods of choice for answering more complex questions. Results of the latter include articulation of multiple perspectives on both positive and negative aspects of POE and a description of what may be important for successful implementation of POE in the future. The present economic environment of hospitals may be inhibiting widespread diffusion of POE, not only because of the direct cost, but also indirectly by affecting relations with practitioners. Analysis of successful past implementations can provide guidance when the time is right.

Effect of ABT-627 (A-147627), a potent selective ET(A) receptor antagonist, on the cardiopulmonary profile of newborn lambs with surgically-induced diaphragmatic hernia

1. Postnatal mortality in isolated congenital diaphragmatic hernia (CDH) is mainly related to the associated pulmonary hypertension (PH) and to right-to-left shunting. 2. Endothelins (ETs) are potent vasoconstrictors and pro-mitogenic peptides. Strong evidences support their participation in CDH and in the etiology of PH via the activation of ET(A) receptors (ET(A)-Rs). 3. Evaluation of the effect of ABT-627, a selective non-peptidic ET(A)-R antagonist, given from -15 to 210 min post-delivery (1 mg kg(-1) bolus +0.01 mg kg(-1) h(-1) infusion, i.v.), was conducted in the lamb model of CDH. 4. Severity of CDH was assessed in comparison to untreated controls (n=5). Untreated CDH lambs (n=7) had a higher mean pulmonary arterial pressure (MPAP; P<0.0001), lower mean blood pressure (MBP; P=0.0004), higher MPAP / MBP ratio (P<0.0001), lower arterial pH (P<0.0001), higher paCO(2) (P<0.0001), lower paO(2) (P<0.0001) and lower post-ductal pulsatile SaO(2) (P<0.0001) than untreated controls. 5. Treated controls (n=7) showed a higher MPAP, lower MBP, higher MPAP/MBP ratio, lower arterial pH, higher paCO(2), lower paO(2), lower post-ductal pulsatile SaO(2) and lower plasmatic ir-ET ratios compared to untreated controls (P<0.0001). 6. Treated CDH lambs (n=8) showed a higher MBP (P<0.0001), lower MPAP / MBP ratio (P<0.0001), higher arterial pH (P<0.0001), lower paCO(2) (P<0.0001), higher paO(2) (P=0.0228), higher post-ductal pulsatile SaO(2) (P=0.0016) and lower plasmatic ir-ET ratios (P=0.0247) when compared to untreated CDH lambs. 7. These observations revealed that, although acute perinatal treatment with a selective non-peptidic ET(A)-R antagonist had some adverse effects in controls, it attenuated the progressive cardiopulmonary deterioration that occurred after birth in CDH lambs.

[Epidemic of Staphylococcus aureus nosocomial infections resistant to methicillin in a maternity ward]

Methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections frequently occur in the hospital environment, but their incidence is less often observed in neonates. In the present investigation, seventeen cases were recorded over a nine-week period (two cases per week). Pulsed field gradient gel electrophoresis confirmed the clonal character of the strain. The hypothesis of manually-transmitted infection due to contamination from multiple sources was reinforced by the fact the epidemic persisted in spite of the elimination of the main human infectious source and an absence of risk factors determined by the case-control study. The role of environmental factors in the persistence of this outbreak of MRSA infection has been considered.

A diffusion of innovations model of physician order entry

OBJECTIVE

To interpret the results of a cross-site study of physician order entry (POE) in hospitals using a diffusion of innovations theory framework.

METHODS

Qualitative study using observation, focus groups, and interviews. Data were analyzed by an interdisciplinary team of researchers using a grounded approach to identify themes. Themes were then interpreted using classical Diffusion of Innovations (DOI) theory as described by Rogers [1].

RESULTS

Four high level themes were identified: organizational issues; clinical and professional issues; technology implementation issues; and issues related to the organization of information and knowledge. Further analysis using the DOI framework indicated that POE is an especially complex information technology innovation when one considers communication, time, and social system issues in addition to attributes of the innovation itself.

CONCLUSION

Implementation strategies for POE should be designed to account for its complex nature. The ideal would be a system that is both customizable and integrated with other parts of the information system, is implemented with maximum involvement of users and high levels of support, and is surrounded by an atmosphere of trust and collaboration.

Unmet needs in the community: can existing services meet them?

OBJECTIVE

This prospective study of community cases examined: (a) needs for care; (b) whether services meet the needs; and (c) personal factors associated with unmet needs.

METHOD

Two separate 'Needs for Care Assessment Schedule Community version' evaluations identified 38 subjects with No Need (NN), 19 with Met Needs (MN) and 25 with Unmet Needs (UNM). Other instruments included the Diagnostic Interview Schedule-Abridged Version (DISSA) and repeated measures of symptoms and social functioning.

RESULTS

(a) Cases did not equate needs. (b) Services utilization did not equate having met needs. (c) Respondents with UNM were more likely to present high rates of lifetime DSM-II-R disorders, no marital relationship ever, no employment, high rates of life events, and physical or sexual abuse in childhood. They have worse outcome in terms of distress and social functioning.

CONCLUSION

Personal factors may prevent respondents from seeking, engaging and benefiting from treatment.

Effect of CGS 26303, an endothelin-converting enzyme-neutral endopeptidase inhibitor, on nitrofen-induced congenital diaphragmatic hernia in the rat

BACKGROUND/PURPOSE

The pathophysiology of congenital diaphragmatic hernia (CDH) associated with lung hypoplasia and pulmonary hypertension is not understood fully. Endothelins (ETs) are the most potent vasoconstrictors that also act as promitogenic agents. They may play a role during pregnancy in leading to the condition found at birth and ongoing mortality in CDH. Therefore, the authors studied the effect of CGS 26303, a nonselective endothelin-converting enzyme and neutral endopeptidase inhibitor, in the rat model of CDH.

METHODS

Pregnant Sprague-Dawley rats were divided into 3 groups: group 1 (n = 4) received CGS 26303 (50 mg/kg, subcutaneously, twice a day), from gestational day 12 until term (21 to 23 days); group 2 (n = 8) received nitrofen (100 mg/kg, orally) at gestational day 11.5; group 3 (n = 8) received both nitrofen and CGS 26303. The survival of the newborn rats was monitored up to 240 minutes. After natural death or euthanasia, they were weighed and microdissected. The degree of hernia was quantified as small, moderate, or severe, and lungs and liver were harvested and weighed.

RESULTS

Newborn rats from mothers of group 3 (n = 81) survived 196 +/- 8 minutes compared with 173 +/- 9 minutes of those of group 2 (n = 97). Severe CDH from group 3 (n = 20) had a mean survival time of 66 +/- 13 minutes compared with 26 +/- 4 minutes for those of group 2 (n = 27). Lung index in severe CDH pups of group 3 was increased by 13% compared with those from group 2 (P < .0001), whereas their liver index went down by 8% (P < .05).

CONCLUSIONS

These results suggest that CGS 26303 might have a beneficial effect when given during pregnancy in increasing survival at birth and reducing the severity of the pulmonary hypoplasia in newborn rats with nitrofen-induced CDH.

[Principles of medical liability and practice in medical imaging]

Radiologists are liable for all aspects of their practice, from the indication of an examination to the radiology report and follow-up, as well as for providing information and recommendations. They are liable for their decisions and actions. They are liable for their competence and continuous medical education. They are also liable for their own equipment and staff. In cases of litigation, the liability of a radiologist may be questioned. Four types of procedures must been known: penal, civil, administrative and disciplinary.

Improved pulmonary function after surgical reduction of congenital diaphragmatic hernia in lambs

BACKGROUND/PURPOSE

Modern trends are toward delayed surgical reduction of congenital diaphragmatic hernia. This study was conducted to verify the hypothesis that the "ease" of ventilation found in the authors' postoperative experience in infants with congenital diaphragmatic hernia (CDH) is associated with postsurgical improvement in pulmonary mechanics.

METHODS

Very severe CDH was surgically induced in utero at 90 days' gestation in 31 lambs. At birth pulmonary mechanics (PeDS-Lab) was measured in these preterm lambs with (n = 24) and without (n = 7) early surgical reduction, and in eight non-CDH controls over the same period; functional residual capacity (FRC) also was obtained from 14 of the 31 CDH lambs (seven reduced animals and seven unreduced ones). Management excluded aspiration from the thorax and insertion of chest drains.

RESULTS

After 30 minutes of life CDH animals with early surgical reduction demonstrated significantly greater improvement in lung volume, pulmonary mechanics, and oxygenation than those without reduction: FRC, 235% versus 19%; compliance, 57% versus 14%; minute ventilation, 71% versus 30%; and PO2, 143% versus -15%. Over the same period, in preterm controls without CDH, only the compliance varied significantly, demonstrating a 32% increase.

CONCLUSION

Based on the mechanics of breathing in these lambs, the authors speculate that neonates with CDH could benefit from early surgical repair because of improvement in pulmonary function, provided extra care is taken to prevent pulmonary overdistension.

Computed tomography of superior mesenteric vein thrombosis following appendectomy

During a 5-year period, superior mesenteric vein (SMV) thrombosis was detected with computed tomography (CT) in six patients shortly after an appendectomy. No sign of SMV was present at appendectomy, and a period of more than 2 weeks free of clinical symptoms had elapsed between the appendectomy and the onset of the SMV thrombosis. In four cases, the appendicitis was complicated. These patients had nonspecific signs and symptoms, although two of them had elevation of blood hepatic enzyme levels. In all cases, postcontrast CT demonstrated enlargement of the SMV, with well-defined enhancement of the vascular wall and an intraluminal clot. In one case, CT showed extension of the thrombus to the portal vein with the presence of low-attenuation areas in the liver, consistent with hepatic infarcts. Two patients had predisposing diseases: idiopathic hypersplenism in one case and chronic hepatic disease in the other. SMV thrombosis is a possible complication of appendicitis, and early appendectomy in appendicitis can prevent this complication. Moreover, as in any abdominal surgery, early appendectomy may be complicated by thrombosis of the SMV, thus creating problems of postoperative diagnosis. The complication is more frequent when the initial operation is performed under difficult conditions (peritonitis), or when the patient presents with a coagulopathy. CT is useful in the diagnosis of SMV thrombosis, thus leading to early management with anticoagulant therapy, with a view to avoiding complications such as intestinal ischemia, portal vein thrombosis, and hepatic infarction.

Retinol status of newborn infants with congenital diaphragmatic hernia

The etiology of congenital diaphragmatic hernia (CDH) is not yet known. Studies in the literature from 1941 have reported that nutritional deficiency of vitamin A during pregnancy could lead to CDH, associated or not with other malformations in young rats. More recently, possible correlations between expression patterns of cellular retinoid-binding protein and retinoic-acid receptors and morphologic effects of vitamin A deficiency have been suggested. The purpose of this study was to verify in human newborns the possible link between vitamin A deficiency and CDH previously observed in experimental animals. Blood samples were obtained during the first hours after birth from 11 term CDH newborns and 11 healthy controls matched for gestational age, and also from 7 mothers in each group, for a total of 7 newborn-mother pairs of matched CDH-controls. Plasma retinol was measured by high-performance liquid chromatography and retinol-binding protein (RBP) by nephelometry. In the 11 matched CDH-control newborns, plasma retinol and RBP levels in CDH newborns were 50% less than control values (P< 0.0002 and <0.006, respectively); in contrast, retinol levels in CDH mothers were significantly higher than those of control mothers (P < 0.005). The observation that the plasma concentrations of retinol and RBP are low in infants with CDH relative to controls may be clinically very relevant and may help to elucidate the mechanism of development of this congenital anomaly.

Factors related to utilization of services for mental health reasons in Montreal, Canada

This study examines factors related to the utilization of services for mental health reasons by Montreal residents. Data were drawn from telephone interviews. A random sample of 893 respondents completed a questionnaire on service utilization and the Diagnostic Interview Schedule Self Administered to assess DSM-III-R psychiatric disorders. Results indicate that 12.8% of the population had used such services in the past year. Medical doctors and psychiatrists, whose services are free of charge under universal health coverage, were consulted, respectively, by 4.1% and 2.0% of respondents. Psychologists, whose services are not free, were seen by 3.4% of respondents. In all, 42.0% of respondents who presented a current diagnosis used services in the past year. The highest proportion of users (48.0%) was found among respondents who presented both current and lifetime diagnoses and among respondents with comorbidity. The choice of caregiver was related also to pattern of disorders: respondents with current and comorbid disorders tended to consult general practitioners, while respondents with lifetime disorders or with lifetime and current disorders favoured specialized care. In line with other studies, self-perception of mental health, gender and marital status were related to utilization; unlike other studies, attitudes and age were not. It is argued that particularities found in this study stem not only from methodological considerations, but also from the configuration of the mental health system in Quebec, where the greater availability of psychologists may facilitate service utilization.

Telephone surveys as an alternative for estimating prevalence of mental disorders and service utilization: a Montreal catchment area study

BACKGROUND

Large-scale mental health surveys have provided invaluable information regarding the prevalence of specific mental disorders and service use for mental health reasons. Unfortunately, because vast surveys conducted face to face are very costly, many countries and provinces do not embark upon this path of research, thus depriving themselves of a rich source of data useful for service planning.

METHOD

As an alternative, the authors undertook a telephone survey with a sample of 893 residents from a Montreal catchment area. Mental disorders were assessed by the Composite International Diagnostic Interview Simplified (CIDIS), an instrument especially designed to be used in mail or telephone surveys. Service utilization was measured by an instrument similar to those used in recent large Canadian or American surveys.

RESULTS

The prevalence rate for any mental disorder was lower in this study than in some large-scale epidemiological surveys reviewed. This could be explained by methodological differences, such as number of disorders covered and period of reference. With regard to specific mental disorders, results appeared very similar to those of other studies. Concerning service utilization, rates tended to be higher than in other studies, and this finding could reflect real differences between Quebec and other Canadian provinces or the United States.

CONCLUSIONS

Aside from being lower in cost, telephone surveys can yield results comparable to those obtained in large-scale epidemiological surveys conducted by means of face-to-face interviews.

Small bowel obstruction: role and contribution of sonography

The purpose of this study was to determine whether sonography provides additional clinical information in patients suspected of small bowel (SB) obstruction. During a period of 30 months, in a prospective setting, we evaluated with sonography 123 patients suspected of SB obstruction. Sonographic examinations of the entire abdomen were performed with state-of-the-art, real-time, grey-scale equipment. Fourteen patients were labelled 'gassy' and no added information was provided following abdominal ultrasound. Sonography confirmed the SB obstruction in 82 cases with 5 false positives, resulting in a specificity of 82.1 %. Sonographic examinations were negative in 27 cases with 4 false negatives and a sensitivity of 95 %. The accuracy was 91.7 % when the 'gassy' patients were excluded and 81.3 % overall. The aetiology of the ileus was detected by sonography in 13 cases of paralytic ileus (54.1 %) and in 57 cases of mechanical ileus (71.4 %). It is concluded that ultrasound, which is a non-invasive, portable and even bedside imaging procedure, appears accurate in confirming a SB obstruction and in determining the aetiology of SB obstruction.

Oncogenic activation of RET by two distinct FMTC mutations affecting the tyrosine kinase domain

Multiple endocrine neoplasia type 2A (MEN 2A) and familial medullary thyroid carcinoma (FMTC) are two dominantly inherited disorders caused by germline mutations of the RET proto-oncogene. The RET gene codes for a receptor tyrosine kinase. The majority of MEN2A and FMTC mutations are clustered in the extra-cellular cysteine-rich domain and result in constitutive activation of the tyrosine kinase through the formation of disulfide-bonded RET homodimers. Recently, two novel point mutations have been identified in the germline of five distinct FMTC families. Both mutations occur within the catalytic domain of the RET kinase and lead to the substitution of either glutamic acid 768 or valine 804 by an aspartic acid and a leucine respectively. We have introduced each FMTC mutation in two RET isoforms: RET51 the long isoform (1114 aa) and RET9 the short isoform (1072 aa) which differ in the C-terminal region of the protein. The RET51 isoform carrying either E768D or V804L mutation was autophosphorylated, displayed a transforming activity upon expression in Rat1 fibroblasts and induced neuronal differentiation of PC12 cells. However, the transforming capacity of these RET51-FMTC mutants was found to be severalfold less potent compared to the same isoform carrying either the MEN2A mutation (C634R) or the MEN2B mutation (M918T). In contrast, RET9 containing mutations E768D or V804L was not autophosphorylated, exhibited a poor oncogenic potential in fibroblasts and did not promote neuritic outgrowth upon expression in PC12 cells. Overall, these findings demonstrate that mutations E768D and V804L are gain-of-function mutations that confer to the long RET isoform the capacity to exert a biological effect, although these mutations are more weakly activating than the MEN2A and MEN2B mutations. These results may provide a biochemical basis as to why the phenotypic consequences of these mutations are restricted to thyroid C-cells.

Psychometric properties of the Interpersonal Relationship Inventory with a homeless sample

This paper examined the psychometric properties of the Interpersonal Relationship Inventory with a sample of homeless men who were first-time shelter users. The measure, based on social exchange theory and equity theory, has two subscales, one for support and the other for conflict. As yet, few measurements have been developed to assess conflict from within social networks. As part of a larger longitudinal study a sample of 166 first-time shelter users was administered the inventory. A student sample also filled out the inventory for comparison purposes. Internal consistency for both subscales was good, .90 for Support and .83 for Conflict. Weak interitem correlations were prevalent among many items in the Conflict subscale. A nearly zero correlation was found between scores on the Support and Conflict subscales, suggesting independence. An exploratory factor analysis using varimax rotation confirmed a dual factor structure. Analyses of variance and Scheffé contrast tests detected no statistically significant differences between age groups on either the Support or the Conflict subscales. A multiple regression analysis indicated that, when controlling for age, scores on the Support scale discriminated the homeless and student samples, while scores on the Conflict subscale do not. The Support subscale indicates excellent psychometric qualities, while the Conflict subscale should be refined.

Morphometrics of normal and hypoplastic lungs in preterm lambs with gas and partial liquid ventilation

To test the hypothesis that perfluorochemical (PFC) instillation may reduce the pulmonary trauma commonly associated with conventional gas ventilation, we studied 12 lambs with normal lungs and 10 with pulmonary hypoplasia secondary to congenital diaphragmatic hernia (CDH). We used mechanical ventilation for up to 3.5 h, with and without tracheal instillation of LiquiVent PFC liquid. At the end of experimentation lungs were fixed for morphometrical analysis of their components and pulmonary trauma was evaluated by measurement of the perivascular compression index (PCI = % perivascular emphysema/% vessels). In normal lungs good gas exchange and respiratory mechanics were obtained with all modes of ventilation, with no statistical difference in the index of pulmonary trauma with or without instillation of LiquiVent (P >0.05). In the hypoplastic lungs, tracheal instillation of PFC liquid after 30 min of conventional gas ventilation significantly improved PaCO2 (from 107+/-8 to 55+/-6 mmHg, P <0.05), pH (from 7.00+/-0.03 to 7.29+/-0. 04, P <0.05), compliance (from 0.08+/-0.01 to 0.25+/-0.03 ml/cmH2O . kg, P <0.05), and ventilatory index (from 1,445+/-148 to 794+/-139, P <0.05). Survival was 6/6 animals with PFC ventilation compared to 1/4 with conventional gas ventilation with no more pulmonary trauma (mean PCI 12.6+/-1.8 vs. 11.4+/-4.0%, P >0.05) for a longer mean ventilatory period in the PFC group. We conclude that the PFC liquid technique of ventilation can improve respiratory physiology when conventional gas ventilation alone is proving inefficient. There was no significant difference in pulmonary trauma at morphometrics between gas and partial liquid ventilation.

Distinct biological properties of two RET isoforms activated by MEN 2A and MEN 2B mutations

Germline mutations of the RET proto-oncogene, which codes for a receptor tyrosine kinase, cause multiple endocrine neoplasia type 2A (MEN 2A) and 2B (MEN 2B) and familial medullary thyroid carcinoma (FMTC). MEN 2 mutations have been shown to result in RET oncogenic activation. The RET gene encodes several isoforms whose biological properties, when altered by MEN 2 mutations, have not been thoroughly addressed yet. In this study, we have introduced a MEN 2A mutation (Cys634-->Arg) and the unique MEN 2B mutation (Met918-->Thr) in two RET isoforms of 1114 and 1072 amino acids which differ in the carboxy-terminus part. Herein, we report that each RET isoform activated by MEN 2A or MEN 2B mutation was transforming in fibroblasts and induced neuronal differentiation of pheochromocytoma PC12 cells. However, among the different RET-MEN 2 mutants, the long RET isoform activated by the MEN 2B mutation stimulated the most prominent neurite outgrowth in PC12 cells, while the short RET isoform counterpart elicited a very weak differentiation effect in PC12 cells. We further demonstrate that the morphological changes of PC12 cells caused by constitutively activated RET oncoproteins involved the engagement of a Ras-dependent pathway. These findings provide evidence that the biological properties of RET-MEN 2 mutants depend on the interplay between the RET isoforms and the nature of the activating MEN 2 mutation.

Lymphocyte esterases and hydroxylases in neurotoxicology

Certain human lymphocytic enzymes, such as neuropathy target esterase (NTE), have become useful markers in clinical toxicology. NTE has been proposed as a predictive marker in organophosphate poisoning for the subsequent development of organophosphate-induced delayed neuropathy. We studied lymphocyte aryl hydrocarbon hydroxylases, and using a differential method based on that of NTE employing a phenyl-alkanoic substrate, developed an enzyme assay for use in toxic neuropathies. The assayed enzyme, which we refer to as neuropathy target hydroxylase (NTH), performed similarly to NTE in the evaluation of coherent clinical data obtained in patients with toxic neuropathies. This study indicates good correlation between the severity of clinical illness and abnormally low levels of NTH in neuropathies of varied etiology. A simplified protocol for NTH assay is presented.

Incidence of transient congenital hypothyroidism due to maternal thyrotropin receptor-blocking antibodies in over one million babies

To determine the incidence of transient congenital hypothyroidism due to TSH receptor-blocking antibodies, we screened dried blood specimens obtained from 788 neonates identified as having possible congenital hypothyroidism (from a total population of 1,614,166 babies) and 121 controls. A RRA was used. The potency of blood spot TSH binding inhibitory activity was compared with the severity of congenital hypothyroidism to assess the possible etiological relationship. Maternal serum was studied to confirm the presence of blocking antibodies by both RRA and bioassay. Blood spots obtained from 9 infants contained potent TSH receptor-blocking activity. Samples from 2 additional babies, studied because of clinical suspicion of the disease, were also positive. Long term outcome was known in 8 of the 11 babies, and all had transient disease. Neonates with TSH receptor-blocking activity greater than 132 U/L had a significantly lower T4 level (P < 0.05) and higher TSH (P < 0.005) than those in whom TSH binding-inhibitory activity was less than 132 U/L. All 9 mothers had autoimmune thyroid disease, and 3 had more than 1 affected child. Potent blocking activity was present in 7 maternal serum samples as long as 7 yr after the births of their affected babies. We conclude that measurement of TSH binding-inhibitory activity in dried neonatal blood specimens is a simple and effective method to predict the occurrence of transient congenital hypothyroidism. The incidence of this disorder in North America is 1 in 180,000 normal infants, or approximately 2% of babies with congenital hypothyroidism.

The reliability of the community version of the MRC Needs for Care Assessment

One hundred and nine adults were screened in the community using the abridged version of the CIDI (CIDIS). The subjects comprised DSM-III-R current cases (N = 48), lifetime cases (N = 31) and non-cases (N = 30). The interviews with the 109 subjects were conducted by one of two pairs of clinicians and videotaped. Each interviewer-pair included a psychiatrist and a clinical psychologist. They rated the community version of the Needs for Care (NFCAS-C) by consensus. The other pair of judges then viewed the video and rated the NFCAS-C independently. The agreement on overall needs was excellent (kappa = 0.75), and very good for four of the seven specific sections (from kappa = 0.61 to 0.81). One section could not be rated because of low prevalence, and agreement was less good for the remaining two sections. Agreement was good on specific interventions (medication, kappa = 0.60; specific psychotherapy, kappa = 0.55), but poor on non-specific interventions. The majority of disagreements were due to differences in clinical judgement rather than to technical errors. A new instruction manual has been produced and should help training as well as stabilizing reliability. In devising reliable and valid instruments based on clinical judgement, a balance must be achieved between enhancing reliability with more precise rules and constraining clinical judgement so tightly that validity is lost.

[Neural crest and multiple endocrinopathies]

Multiple endocrine neoplasia type 2 (MEN 2) is a cancer syndrome which comprises three related disorders, MEN type 2A (MEN 2A), type 2B (MEN 2B) and familial medullary thyroid carcinoma (FMTC), MEN 2A is characterized by the association of MTC, a tumour arising from thyroid C-cells, pheochromocytoma and parathyroid hyperplasia. In addition to the thyroid cancer, MEN 2B associates pheochromocytoma, mucosal neuromas, ganglioneuromatosis of the digestive tract and skeletal abnormalities. In FMTC, the MTC is the sole clinical manifestation. MEN 2 is a dominantly inherited neural crest disorder caused by germline mutations of the RET proto-oncogene. The RET gene encodes a receptor tyrosine kinase, which displays a cadherin-like domain and a cysteine rich motif in its extracellular part. Missense mutations at one of five cysteines clustered in the extra-cytoplasmic domain of RET have been identified in the majority of the MEN 2A families and in two-thirds of FMTC. A single point mutation leading to the replacement of a methionine by a threonine within the tyrosine kinase domain has been detected in almost all cases of MEN 2B. We have screened 170 french MEN 2 families and a germline mutations in the RET gene have been identified in 92% of cases. Moreover, we confirmed the significant correlation between the nature, the position of the RET mutations and the clinical phenotype. The accurate identification by DNA testing of individual predisposed to MEN 2 suggests new protocols of treatment. Thyroidectomy as early as 6 years of age in individuals with MEN 2 mutations has been recently advocated by clinicians. We further provide evidence that MEN 2A and MEN 2B mutations convert the RET proto-oncogene in a dominantly-acting transforming gene due to the ligand-independent constitutive activation of the tyrosine kinase. Finally, we have constructed transgenic mice carrying the RET gene carrying a MEN 2A mutation fused to the calcitonin gene related peptide/calcitonin promoter. Animals of three independent transgenic lines developed C-cell hyperplasia and subsequently MTC with a complete penetrance. Taken together, these findings indicate that MEN 2A form of RET is oncogenic in thyroid C-cells, and suggest that these transgenic animals should prove a valuable model for hereditary MTC. Future work should yield insights in the signaling pathways subverted by the RET-MEN 2 proteins.

Bone mineral acquisition during adolescence and early adulthood: a study in 574 healthy females 10-24 years of age

Low bone mass is known to be associated with an increased risk of fractures. Osteoporosis prevention by maximizing bone mass will be crucial and requires a better knowledge of bone mass acquisition during adolescence. Bone mass was assessed in 574 healthy volunteer females aged 10-24 years. Spine bone mineral density (BMD) in anteroposterior (AP L2-4) and lateral (LAT L3) views was measured using dual-energy X-ray absorptiometry (DXA) and AP bone mineral content (BMC) was calculated. At the same time, spine AP-BMD (L2-4) was evaluated in 333 normal menstruating women, aged 27-47 years. Bone values, osteocalcin and IGF-1 serum concentrations were correlated with chronological age, skeletal age, pubertal stages and time after menarche. In this cross-sectional study, AP- and LAT-BMD and BMC increased dramatically between skeletal ages 10 and 14 or until the first year after menarche. Between 14 and 17 skeletal years of age, AP-BMD and BMC increased moderately, whereas LAT-BMD remained unchanged. After skeletal age 17, or the fourth year after menarche, there was no significant increase in BMD or BMC, and their values did not differ from those of menstruating women. A serum osteocalcin peak was observed at skeletal ages 11-12 or at stage P3, whereas IGF-1 peaked at 13-14 skeletal years of age or at P4 and the first year after menarche. Eighty-six per cent of the adult bone mass of the spine is acquired before skeletal age 14 or the second year after menarche; therefore osteoporosis prevention programs will be particularly effective before that age.