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

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

Metastatic soft tissue squamous cell carcinoma

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

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

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

Gastrointestinal stromal tumors: analysis of clinical and pathologic factors

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

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

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

OBJECTIVES

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

DESIGN

Two serial cross sectional surveys.

SUBJECTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

An HLB-B null allele (B*0808N) caused by a nucleotide deletion in exon 3, found in the family of a bone marrow transplant recipient

We have identified a variant HLA-B allele, B*0808N, segregating through two generations of healthy individuals, whilst HLA typing the family of a bone marrow patient. Serological typing identified a disparity between the father (A1, A3 B7 DR7) and the brother (A1, A2 B56 DR1, DR7) of the patient. Low/medium resolution polymerase chain reaction using sequence-specific primers (PCR-SSP) revealed a B*08 allele undetectable by serological methods. High resolution DNA typing by polymerase chain reaction-sequencing based typing (PCR-SBT), revealed a nucleotide deletion at position 131 (C) in exon 3, the only difference between the new allele and B*0801. The deletion results in a frame shift in the protein coding sequence, introducing a premature termination codon (TGA) in exon 4. Although a B*08 allele is present in these individuals, the deletion prevents correct expression of the antigen on the cell surface.

Identification of the null HLA-A2 allele, A*0232N

We have identified a null HLA-A*02 allele, HLA-A*0232N, by using a combination of serology, flow cytometry, polymerase chain reaction using sequence-specific primers (PCR-SSP) and full-length sequencing. The null HLA-A2 allele was identified in an Asian individual originally typed by serology as an apparently homozygous HLA-A3, B51. Subsequent genotyping by PCR-SSP identified the genotype as HLA-A*0201, *0301, B*51, Cw*1402. The serological type and lack of detectable HLA-A2 was confirmed using monoclonal antibody typing reagents. Flow cytometry studies failed to identify any cell surface HLA-A2 expression on the patient's peripheral blood lymphocytes. Genotyping using a PCR-SSP set designed to detect null alleles revealed the mutation had not been previously described. Full-length sequencing of the allele identified an allele which was subsequently named HLA-A*0232N. This allele is identical to HLA-A*0201 except for a novel point mutation (T for C) at position 493 which creates a premature stop codon. The sequencing enabled the development of a monospecific A*0232N PCR-SSP reaction which was used to screen 973 DNA samples: no further examples of A*0232N were identified.

An analytic method for longitudinal mortality studies

Our knowledge of mortality risks comes largely from longitudinal (cohort) studies. The most commonly used analytic tool is the Cox proportional hazards model for survival analysis. An alternative approach is a simple cross-sectional analysis of person-years. The key to the method is logistic regression, where the outcome variable is lived/died in the given year and the explanatory variables are age, sex, and other potential risk factors. This approach can be used to model any dichotomous outcome and has several important advantages over the more traditional survival analysis. As an example, we compare the two methods using a large data base of patients with spinal cord injury.

Identification of a novel allele, B*15012, by polymerase chain reaction using sequence-specific primers (PCR-SSP) and sequence-based typing

We report here a new allele, B*15012, identified by polymerase chain reaction using sequence-specific primers (PCR-SSP) and sequence-based typing (SBT). B*15012 differs to B*15011 (previously named B*1501) by a single nucleotide, at position 435 of codon 120. B*15011 encodes AAG and B*15012 encodes AAA at codon 120, this difference does not result in an amino acid change.

Identification of an HLA-B7 serological variant and its characterization by sequencing based typing

We have identified an HLA-B*07 variant allele, B*0716, in a Caucasoid cadaver kidney donor. The HLA class I type by polymerase chain reaction using sequence-specific primers (PCR-SSP) was A*01, 32; B*07, 08; Cw*07. Serological typing, using monoclonal and polyclonal anti-HLA antisera, gave disparate results for the B antigens. Monoclonal antibodies identified B7 and B8 antigens but polyclonal antisera recognised only the B8 antigen. PCR using sequencing based typing (PCR-SBT) confirmed the presence of both B*0703 and B*0801 alleles but with a mutation in one of the alleles. The HLA-B*07 allele was isolated by allele-specific PCR and was shown to have a mutation, G-->T, at 292 in exon 2. This mutation changes codon 74, which encodes aspartic acid (GAC) present in all previously identified B*07 alleles, to tyrosine (TAC) in the variant. The serological results suggest that codon 74 is a crucial part of a B7 antigen-specific epitope recognised by tissue typing polyclonal antisera.

Implementation of a clinical pathway system in maternal newborn care: a comprehensive documentation system for outcomes management

This article describes the design, implementation, and evaluation of an interdisciplinary clinical pathway system for maternal newborn care in a perinatal regional referral institution. Core issues in the design of this system are addressed to promote outcomes management and ongoing performance improvement. A discussion of the implementation follows, illustrating the lessons learned, changes made, and associated evaluation. This clinical pathway system has improved communication and collaboration among all disciplines, enhanced the discharge coordination process, and established protocols available to all members of the health care team.

The development of an in-house leg ulcer management course

A description of a course designed to standardise leg ulcer management.

Risky business: health and safety in the sex industry over a 9 year period

OBJECTIVES

To assess whether a previously established low sexually transmitted infection/HIV risk in prostitutes in London has been sustained, and to measure other occupational risks, including mortality.

DESIGN

9 year prospective study in west London.

SUBJECTS

402 prostitutes recruited from 1985 to 1991, 320 were followed up for 675 person years to 1994.

MAIN OUTCOME MEASURES

Condom use in commercial and non-commercial sex; viral and bacterial sexually transmitted infection at initial and follow up visits; death.

RESULTS

Condom use increased significantly from 1986 to 1993 and protected the majority of commercial sexual contacts. Baseline prevalence: HIV 1.3%, hepatitis C 6.7%, hepatitis B 6.6%, syphilis 2.3%, HTLV-I/II 0.4%, gonorrhoea 3.0%, chlamydia 8.2%, genital herpes 16.8%. Incidence (per 100 person years): HIV 0.2, hepatitis C 0.3, gonorrhoea 5.6, chlamydia 12.6, genital herpes 6.5. Viral infections were associated with injecting drug use and non-British nationality; bacterial infections were associated with numbers of non-commercial partners but not with sexual contacts at work. Four women died during the course of the study; two had AIDS, two were murdered. This mortality of 5.93 per 1000 person years was 12 times the expected rate for women of a similar age.

CONCLUSIONS

This study shows that it is possible to have a larger number of sexual partners and remain free from sexually transmitted infections provided that condoms are used consistently: there has been a sustained increase in condom use in the sex industry. None the less, prostitutes are at increased risk of sexually transmitted infections, primarily through non-commercial sexual partnerships. Infectious diseases are only one of the risks facing prostitutes, as illustrated by the mortality from violence as well as from HIV infection.

Plasminogen II accumulates five times faster than plasminogen I at the site of a balloon de-endothelializing injury in vivo to the rabbit aorta: comparison with other hemostatic proteins

In the rabbit blood stream, plasminogen circulates as two glycoforms, plasminogen I (PLG-I) and plasminogen II (PLG-II), in a molar ratio of 1:2.2. To compare their relative behaviors toward a site of vascular injury, radiolabeled samples of PLG-I and PLG-II were coinjected intravenously into NZW rabbits before inducing a de-endothelializing (balloon catheter) injury to the thoracic aorta. At various times (5 to 60 minutes) after injury, each rabbit was anesthetized and exsanguinated, the aorta was excised, and the radioactivity per centimeters squared of aortic intima-media (IM) was measured relative to that of blood at exsanguination. The uptake of iodine 125-labeled PLG-I and iodine 131-labeled PLG-II showed that the IM was essentially saturated by both glycoforms by 30 to 40 minutes after injury. Extrapolation of the flux rates to 1 minute after injury indicated that the uptake of PLG-II (2.4 pmol/min/cm2) exceeded PLG-I (0.5 pmol/min/cm2) almost five-fold. This result is consistent with an earlier report (Metabolism 1994;43:1430-7) that PLG-II is released by the liver and catabolized in vivo approximately five times faster than PLG-I. By molar comparison, the flux of total plasminogen (ie, PLG-I plus PLG-II) into the injured aorta wall in vivo was 2.4 times greater than that for prothrombin. Assuming both zymogens are converted to their respective proteases within the wound site, then approximately 2 to 3 molecules of plasmin are released for each molecule of thrombin in vivo. The possible significance of this plasmin:thrombin ratio is discussed in respect to the turnover of fibrin(ogen) within the site of vascular injury.

Identification of an HLA-A11 serological variant and its characterization by sequencing based typing

We have identified an HLA-A11 variant allele, A*1105, segregating in a Caucasoid family. The variant antigen expressed by this allele failed to cross-react with most Caucasoid anti-HLA-A11 antisera tested. Sequencing based typing has been used to characterize this new allele and this showed that it has a novel mutation at a polymorphic position (502) in exon 3. In comparison with A*1101, the mutation (A-->G) results in an amino acid change from positively-charged lysine to negative glutamate and this may explain the altered HLA-A11 serological profile exhibited by this antigen. The new allele was found in a patient with acute lymphoid leukaemia (ALL), her father and two siblings.

Identification of a new variant, HLA-Cw*1507, differing from Cw*1502 only at the KIR-related dimorphism of codons 77 and 80

We describe here a novel allele, HLA-Cw*1507, identified by polymerase chain reaction using sequence-specific primers (PCR-SSP) and sequence-based typing (SBT). Cw*1507 is similar to Cw*1502 with differences at nucleotide positions 302 (A to G) and 312 (A to C) in exon 2. The substitutions observed in Cw*1507, change codon 77 from AAC (asparagine) to AGC (serine) and codon 80 from AAA (lysine) to AAC (asparagine), compared to Cw*1502. Residues 77 and 80 of HLA-C alleles are located in the alpha 1 domain, where they can influence interaction between antigenic peptides and the T-cell receptor. Also, the dimorphism at these residues from asparagine and lysine to serine and asparagine, respectively, are known to modulate interaction with the natural killer (NK) cell killer inhibitory receptor (KIR). The new HLA-Cw*1507, together with Cw*1502, represents the fourth pair of HLA-C alleles differing only at the KIR-related dimorphic codons 77 and 80.

Indirect evidence of human skeletal muscle damage and collagen breakdown after eccentric muscle actions

Indirect markers of muscle damage and collagen breakdown were recorded for up to 9 days after a bout of concentric, followed by a bout of eccentric, muscle actions. Nine untrained participants performed two bouts of 50 maximum effort repetitions on an isokinetic dynamometer (angular velocity 1.05 rad x s(-1), range of motion 1.75 rad). An initial concentric bout of muscle actions was followed by an eccentric bout 21 days later, using the same knee extensors. Concentric actions induced no changes in maximum voluntary isometric contraction force (MVC), nor induced any changes in the serum enzyme activities of creatine kinase, a lactate dehydrogenase isoenzyme (LDH-1), or alkaline phosphatase. Similarly, concentric actions induced no change in markers of collagen breakdown, namely plasma hydroxyproline and serum type 1 collagen concentration. In contrast, eccentric actions induced a 23.5+/-19.0% (mean+/-s) decrease in MVC immediately post-exercise (P < 0.05), and increased the serum enzyme activities of creatine kinase and LDH-1 to 486+/-792 and 90+/-11 IU.l(-1) respectively on day 3 post-exercise, and to 189+/-159 and 96+/-13 IU x l(-1) respectively on day 7 post-exercise (all P< 0.05). Eccentric actions induced no significant changes in plasma hydroxyproline, but increased collagen concentration on days 1 and 9 post-exercise (48.6% and 44.3% increases above pre-exercise on days 1 and 9 respectively; both P < 0.05). We conclude that eccentric but not concentric actions may result in temporary muscle damage, and that collagen breakdown may also be affected by eccentric actions. With caution, indices of collagen breakdown may be used to identify exercise-induced damage to connective tissue.

Flow cytometry and squamous cell carcinoma of the maxillary sinus: A possible prognostic indicator for multimodality intervention

Malignant tumors of the paranasal sinuses constitute less than 1% of all malignancies. Unfortunately, few prognostic factors have been identified regarding the efficacy of interventional therapy. Patients with carcinoma of the maxillary sinus frequently present with an advanced stage of disease and multimodality therapy is often proposed. Although some tumors appear to be more sensitive to preoperative chemotherapy and radiation therapy, a method of predicting and evaluating tumor behavior has not been recognized. Introduced as a means of identifying cell populations with abnormalities in total DNA content, flow-cytometric DNA analysis provides a quick and reliable means of tumor characterization for many malignancies. Although nuclear DNA content has been implicated as a prognostic factor in an increasing number of tumor types, current data on the role of DNA content in head and neck carcinoma is conflicting and incomplete. To evaluate the role of flow-cytometric DNA analysis in predicting therapeutic alternatives, 22 patients with squamous cell carcinoma of the maxillary sinus were reviewed. Patient outcome and histopathologic grade were retrospectively compared with flow-cytometric evaluations of paraffin-embedded formalin-fixed tumor specimens. Four of sixteen tumors (25%) were found to be aneuploid and were also associated with an increased survival rate (p < 0.01). This initial data emphasizes the possible usefulness of DNA measurement for characterization of squamous cell carcinoma of the maxillary sinus and stresses the need for further evaluation.

Delusional ideation in religious and psychotic populations

OBJECTIVES

Previous research into schizotypy has shown that certain groups of people have similar experiences to the positive symptoms of schizophrenia but remain functioning members of society, such as those with profound religious experiences (Jackson & Fulford, 1997).

METHOD

The focus of the present study was to explore the incidence of delusional ideation in New Religious Movements (NRMs). Hare Krishnas and Druids were compared to two control groups (non-religious and Christian), and to deluded, psychotic in-patients on two delusions measures.

RESULTS

As predicted, individuals from the NRMs scored significantly higher than the control groups on all the delusional measures apart from levels of distress. They did not show as much florid symptomatology as the psychotic patients, but could not be differentiated from the deluded group on the number of delusional items endorsed on the Peters et al. Delusions Inventory (PDI; Peters, Day & Garety, 1996), or on levels of conviction. However, they were significantly less distressed and preoccupied by their experiences. No differences were found between the two control groups on any of the delusional measures, suggesting that religious beliefs per se do not account for the NRMs members' scores.

DISCUSSION

These findings provide further support for, first, the notion of a continuum between normality and psychosis and, second, for the necessity to consider the multidimensionality of delusional beliefs.

A novel HLA allele, HLA-B*5113, identified in the Kolla Amerindians of North-West Argentina

A novel HLA-B51 allele, B*5113, was identified in a Kolla Amerindian individual from North-West Argentina. HLA-B*5113 differs from B*51011 by two nucleotide substitutions, one synonymous, the other nonsynonymous. The resulting amino acid difference at residue 116 in the HLA-B molecule's peptide binding site is likely to affect the nature of the peptides which bind to this molecule. The finding of this novel allele supports previous findings of increased diversity at HLA-B in Amerindian groups.

Changes in indices of antioxidant status, lipid peroxidation and inflammation in human skeletal muscle after eccentric muscle actions

This study investigated the effects of chronic muscle inflammation on indices of antioxidant status and muscle injury after eccentric exercise. Eight subjects each performed 70 maximal voluntary eccentric muscle actions on an isokinetic dynamometer, using the knee extensors of a single leg. Venous blood samples were collected into serum and EDTA tubes 5 and 3 days before exercise, immediately before exercise, and then again on days 3, 4, 5, 6, 7, 10 and 12 after the bout. Needle biopsies were taken from the vastus lateralis of six subjects, a week before exercise (baseline), and again on days 4 and 7 post-exercise. The concentrations of malondialdehyde in plasma and muscle were used as markers of lipid peroxidation. Creatine kinase activity, beta-glucuronidase activity and total antioxidant capacity were determined in serum. In muscle, aqueous and bound total antioxidant capacity, the aqueous sulphydryl concentration, and beta-glucuronidase and glucose-6-phosphate dehydrogenase activity were determined. No changes were detected in serum total antioxidant capacity, serum creatine kinase and beta-glucuronidase after the baseline biopsy. After exercise serum creatine kinase and beta-glucuronidase were elevated although other serum measures were unchanged. In muscle, aqueous and bound total antioxidant capacity, sulphydryls, glucose-6-phosphate dehydrogenase and beta-glucuronidase were all elevated. Despite evidence of inflammation in this study, muscle antioxidant status was not compromised, and malondialdehyde was unaltered in muscle and plasma. Therefore, this study provides no evidence that chronic muscle inflammation compromises antioxidant status or increases lipid peroxidation.

Identification of an HLA-C variant allele, Cw*0805, by sequencing based typing

We have identified a variant HLA-C allele, Cw*0805, in DNA isolated from a blood sample used in the UK National External Quality Assessment Scheme for Histocompatibility and Immunogenetics. The DNA was initially typed by PCR-SSP and PCR-SBT as Cw*0802, 1602 with a single mismatch in exon 2 of one of the alleles. The two HLA-C alleles were separated by locus- and allele-specific PCRs and sequencing analysis showed that the Cw*0802 allele was variant in this sample, with a single mismatch in exon 2 at position 289.

Sexual networks: the integration of social and genetic data

New methods for studying sexual networks are presented, drawing upon routine procedures followed in genitourinary medicine clinics in the UK for tracing partners and identifying strains of infection. The routine social procedures were developed to incorporate a structured interview. The routine microbiological diagnosis of gonorrhoea was augmented by phenotyping and the development of new genetic techniques for the fine discrimination of gonococcal strains (opa-typing). Selected results from a study in Sheffield, UK show that each method has limitations, when conducted separately, but these are minimised when the methods are combined. Moreover, the use of simple and routine methods of data collection resolve issues of scale and sample that have beset other network studies, as they provide a means of covering a larger and defined population. Popular concepts about these methods are discussed in the conclusion. The integrated approach employed in our research raises questions both about social methods, 'of people who lie, particularly when they talk about sex', and about microbiological methods, 'of genes that tell the truth' and bypass what people say and think altogether. We argue that these stereotypes are misleading insofar as they suggest that genetic techniques can substitute for the social, and we suggest that even the finest discrimination of organisms at the genetic level will never obviate the need for their interpretation in the light of social data.

Partner notification for gonorrhoea: a comparative study with a provincial and a metropolitan UK clinic

OBJECTIVE

To compare partner notification practice and outcomes at a provincial and a metropolitan clinic.

DESIGN

Prospective study, following standardisation of partner notification policy.

SETTINGS

Sheffield Department of Genitourinary Medicine, Royal Hallamshire Hospital and Jefferiss Wing Centre for Sexual Health, St Mary's Hospital, London.

SUBJECTS

Consecutive patients with culture positive gonorrhoea between October 1994 and March 1996 who were interviewed by a health adviser.

RESULTS

In Sheffield, 235 cases reported 659 outstanding contacts, of whom 129 (20%) were subsequently screened, and 65 (50%) had gonorrhoea. At St Mary's 510 cases reported 2176 outstanding contacts, of whom 98 (5%) were known to have been screened, and 53 (54%) had gonorrhoea. Patient or provider referral agreements appeared more productive in Sheffield, where 60% resulted in contact attendance, compared with 13% at St Mary's. Provider referral was used more frequently in Sheffield, for 44% of referrals, compared with 1% at St Mary's. Multivariate analysis showed that partner notification was less effective for casual and short term (< 7 days) partnerships in both centres, and for homosexual men at St Mary's.

CONCLUSION

Partner notification outcomes were better in the provincial setting where contact attendance could be recorded more reliably and provider referral was used more extensively. The high proportion of contacts who remained untraced in both settings indicates the need for complementary screening and prevention initiatives.

Sexual histories, partnerships and networks associated with the transmission of gonorrhoea

We aimed to describe and compare sexual links among people with gonorrhoea, by studying patients in 2 UK departments of genitourinary medicine. Interviews were completed for 510 and 235 cases in London and Sheffield respectively. There was a greater proportion of cases in men, homosexual men, non-white and non-British people and fewer female sex workers in London. Total networks of 1738 people in London and 570 people in Sheffield were described. Large linked heterosexual networks identified in Sheffield were associated with local contact, including men with higher numbers of sexual partners. Condom use for vaginal sex was reported for 11% of heterosexual partnerships in Sheffield, and 27% in London, with little difference between regular and casual partners. It was more difficult to define networks in London due to a high proportion of relatively anonymous contacts. These difficulties suggest that research and interventions may profitably focus upon venues for meeting partners as well as partner notification.

Double data entry: what value, what price?

We challenge the notion that double data entry is either sufficient or necessary to ensure good-quality data in clinical trials. Although we do not completely reject that notion, we quantify some of the effects that poor quality data have on final study results in terms of estimation, significance testing, and power. By introducing digit errors into simulated blood pressure measurements we demonstrate that simple range checks allow us to detect (and therefore correct) the main errors that impact the final study results and conclusions. The errors that cannot easily be detected by such range checks, although possibly numerous, are shown to be of little importance in drawing the correct conclusions from the statistical analysis of data. Exploratory data analysis cannot identify all errors that a second data entry would detect, but on the other hand, not all errors that are found by exploratory data analysis are detectable by double data entry. Double data entry is concerned solely with ensuring, to a high degree of certainty, that what is recorded on the case record form is transcribed into the database. Exploratory data analysis looks beyond the case record form to challenge the plausibility of the written data. In this sense, the second entering of data has some benefit, but the use of exploratory data analysis methods, either as data entry is ongoing or at the end of data entry and as the first stage in an analysis strategy, should always be mandatory.

The use of cold compression dressings after total knee replacement: a randomized controlled trial

This prospective, controlled study compared cold compressive dressings with wool and crepe in the postoperative management of patients undergoing total knee replacement (TKR). Forty TKR patients were assessed for blood loss, pain, swelling, and range of motion. Patients in the cold compression group had less blood loss through suction drainage (982 mL versus 768 mL). A higher proportion of patients in the treatment group did not require blood transfusion postoperatively. Mean opiate requirements were lower in the cold compression group (0.57 versus 0.71 mg/kg/48 hours). The cold compression device appeared to reduce blood loss and pain following TKR.

Sexual networks and the transmission of HIV in London

This paper discusses ways in which empirical research investigating sexual networks can further understanding of the transmission of HIV in London, using information from a 24-month period of participant observation and 53 open-ended, in-depth interviews with eighteen men and one woman who have direct and indirect sexual links with each other. These interviews enabled the identification of a wider sexual network between 154 participants and contacts during the year August 1994-July 1995. The linked network data help to identify pathways of transmission between individuals who are HIV+ and those who are HIV-, as well as sexual links between 'older' and 'younger' men, and with male prostitutes. There appears to be considerable on-going transmission of HIV in London. The majority of participants reported having had unprotected anal and/or vaginal sex within a variety of relationships. The implications of these findings for policies designed to prevent the transmission of HIV are discussed.

Sex workers and the control of sexually transmitted disease

OBJECTIVES

To describe and assess measures to control sexually transmitted diseases (STDs) among sex workers and their partners.

METHODS

A review of medical, historical and social literature, focusing on selected cases.

RESULTS

Measures to control disease in sex workers today are often prompted by concerns about HIV transmission. However, the literature shows that prostitution varies from one place and time to another, together with the risk of sexually transmitted disease. A broad social definition of prostitution rather than a narrow reference to levels of sexual activity is important for effective disease control, as an understanding of the relation between social disadvantage and sexual activity enables the provision of occupational services that sex workers actually want and use. Social prejudice and legal sanctions cause some sex workers and their partners to avoid even the most appropriate and accessible specialist services. Therefore targeted programmes can only complement, and not replace, general measures to control STDs, which are developed for other social groups or the local population as a whole.

CONCLUSIONS

Sex workers and sex work differ from one place to another and so a single model for STD control is inappropriate. None the less, occupational health risks suggest a general need for specialist services. Where these do not compound the disadvantages that sex workers already suffer, medical services are likely to offer significant benefits in prevention, early diagnosis, and treatment of STDs. As the stigma of prostitution leads many people to remain invisible to services, a general health infrastructure and anti-discriminatory measures will be equally important to effective disease control.

Reduction of trachoma in a sub-Saharan village in absence of a disease control programme

BACKGROUND

Trachoma is a leading cause of blindness in the developing world and is most prevalent among people who live in poor rural communities in arid locations.

METHODS

We analysed the results of surveys of trachoma prevalence in Marakissa, a rural village in The Gambia. These surveys were undertaken in 1959, by the Medical Research Council, and in 1987 and 1996 by the Gambian National Eye Care Programme.

FINDINGS

During this 37-year period, the prevalence of active inflammatory trachoma among children aged 0-9 years fell from 65.7 cases per 100 children in 1959 to 2.4 cases per 100 children in 1996. The prevalence also fell dramatically among people of 10-19 years (52.5 to 1.4 per 100) and among people of 20 years and older (36.7 to 0 cases per 100).

INTERPRETATION

The dramatic fall in disease occurrence was paralleled by improvements in sanitation, water supply, education, and access to health care in the village. Of particular importance is that the decline in trachoma occurred without any trachoma-specific intervention.

Molecular mechanism underlying the action of a novel fusion inhibitor of influenza A virus

In the initial stages of influenza virus infection, the hemagglutinin (HA) protein of influenza virus mediates both adsorption and penetration of the virus into the host cell. Recently, we identified and characterized BMY-27709 as an inhibitor of the H1 and H2 subtypes of influenza A virus that specifically inhibits the HA function necessary for virus-cell membrane fusion (G.-X. Luo, R. Colonno, and M. Krystal, Virology 226:66-76, 1996). Studies presented herein show that the inhibition is mediated through specific interaction with the HA protein. This binding represses the low-pH-induced conformational change of the HA protein which is a prerequisite for membrane fusion. In an attempt to define the binding pocket within the HA molecule, a number of drug-resistant viruses have been isolated and characterized. Sequence analyses of the HA gene of these drug-resistant viruses mapped amino acid changes responsible for drug resistance to a region located near the amino terminus of HA2. In addition, we have identified inactive analogs of BMY-27709 which are able to compete out the inhibitory activity of BMY-27709. This finding suggests that inhibition of the HA-mediated membrane fusion by this class of compounds is not solely the result of binding within the HA molecule but requires specific interactions.

Combined sequestration, bronchogenic cyst, and dysgenetic lung simulating congenital lobar emphysema

We report the case of a newborn with bronchopulmonary sequestration, bronchogenic cyst, and dysgenetic lung that radiographically simulated congenital lobar emphysema. We discuss congenital malformations of the lungs and the concept of a continuum in the development of pulmonary anomalies.

Sexual partner networks in the transmission of sexually transmitted diseases. An analysis of gonorrhea cases in Sheffield, UK

BACKGROUND AND OBJECTIVES

Routine contact tracing data on patients with gonorrhea are used to identify sexual partner networks. These are combined with gonococcal typing data to study patterns of transmission. The role of persons in transmission is discussed.

STUDY DESIGN

Contact tracing data on patients with gonorrhea attending the Royal Hallamshire Hospital in Sheffield in 1988 and 1989 are analyzed. Gonococcal strains identified by auxotype/serovar (A/S) class are combined with these data to identify transmission paths.

RESULTS

The network contained 1,272 persons, 724 (77%) of whom had gonorrhea during the study period. Four hundred two clusters of linked cases were identified. The largest cluster, containing 35 persons connected over 16 months, is discussed in greater detail to illustrate how these data may help identify patterns of transmission and the role of persons.

CONCLUSION

Contact tracing data can be used to identify sexual partner networks and to study transmission patterns. Microbiologic data can aid interpretation. An person's risk of acquiring infection depends on indirect links as well as direct links. To understand patterns of transmission it may be important to distinguish between those involved in transmission and those only acquiring infection. Networks established through gonococcal transmission are also relevant to the transmission of other sexually transmitted diseases.

Aspartate at position 57 of nonobese diabetic I-Ag7 beta-chain diminishes the spontaneous incidence of insulin-dependent diabetes mellitus

MHC class II genes have been shown to influence the development of the autoimmune disease insulin-dependent diabetes mellitus (IDDM) in the nonobese diabetic (NOD) mouse. In human IDDM it has been suggested that the presence of an aspartate at position 57 of the DQ beta-chain might be important in determining resistance to development of IDDM. The involvement of MHC class II genes in IDDM was investigated through the introduction of MHC encoding transgenes. We show that introduction of a mutated I-Ag7 Ab gene which encodes an aspartate at position 57 reduces the incidence of IDDM but does not prevent insulitis, sialadenitis, or the development of insulin and nuclear autoantibodies.

Aspartate at position 57 of nonobese diabetic I-Ag7 beta-chain diminishes the spontaneous incidence of insulin-dependent diabetes mellitus

MHC class II genes have been shown to influence the development of the autoimmune disease insulin-dependent diabetes mellitus (IDDM) in the nonobese diabetic (NOD) mouse. In human IDDM it has been suggested that the presence of an aspartate at position 57 of the DQ beta-chain might be important in determining resistance to development of IDDM. The involvement of MHC class II genes in IDDM was investigated through the introduction of MHC encoding transgenes. We show that introduction of a mutated I-Ag7 Ab gene which encodes an aspartate at position 57 reduces the incidence of IDDM but does not prevent insulitis, sialadenitis, or the development of insulin and nuclear autoantibodies.

Vision development in the monocular individual: implications for the mechanisms of normal binocular vision development and the treatment of infantile esotropia

PURPOSE

The purpose of this research is to study the vision development in monocular individuals so as to better understand normal binocular vision development and to refine the treatment of infants with infantile esotropia.

METHODS

Thirty-six subjects with one clinically normal eye and one eye with no vision (no light perception or history of enucleation) are studied. In addition to measurement of standard parameters of development such as visual acuity, measurement of motion processing is made by both optokinetic and electrophysiologic techniques. A comparison is made of vision development among three populations: the monocular population, the normal population, and patients with a history of infantile esotropia. Such comparison is made to study the relative effects of interruption of binocularity and binocular competition. The monocular population represents individuals who have interruption of binocularity, whereas the infantile esotropia population has both interruption of binocularity and binocular competition.

RESULTS

The OKN data suggest that the monucular population is more similar to the normal population than the esotropia population. The electrophysiologic data shows a statistically significant difference in the three populations. Motion processing is more fully developed in the monocular population than in the infantile esotropia population when compared to the normal population.

CONCLUSIONS

1. The development of motion processing appears to be particularly vulnerable to abnormal experience during the first year of life. 2. Monocular subjects have a less abnormal motion processing system when compared to patients with infantile esotropia even when monocularity is congenital. 3. The results indirectly support the premise that prealignment alternate occlusion is of benefit to the patient with infantile esotropia prior to realignment. 4. Development of the motion processing system does not necessarily parallel the development of other binocular functions.

Mycobacteria precipitate an SLE-like syndrome in diabetes-prone NOD mice

Non-obese diabetic (NOD) mice spontaneously develop organ-specific autoimmunity and are widely used as a model for diabetes. Aged NOD mice also exhibit some features of non-organ-specific autoimmune rheumatic disease such as anti-nuclear antibodies and late-onset haemolytic anaemia. Here, we report that a single dose of 2.6 x 10(7) heat-killed bacillus Calmette-Guérin (BCG) i.v. in 8-week-old NOD mice prevented diabetes but precipitated a syndrome similar to systemic lupus erythematosus (SLE). Treated mice developed haemolytic anaemia, anti-DNA and anti-Sm anti-nuclear autoantibodies and an increased severity of sialadenitis. Perivascular lymphocytic infiltration in the kidneys and glomerular immune complex deposition were also found. The action of BCG appeared to be mediated by an adjuvant-like activity as treated mice showed a substantial increase in reticuloendothelial cell function and enhanced antigen presentation capacity.

Effects of muscle length on the EMG-force relationship of the cat soleus muscle studied using non-periodic stimulation of ventral root filaments

The effects of changing the length of the cat soleus muscle on electromyographic (EMG) signals, muscle force and the corresponding EMG-force relationship were assessed using distributed stimulation of ten ventral root filaments and irregular interpulse intervals. EMG-force relationships were first determined for four muscle lengths using a protocol of simultaneous addition and rate modulation of ventral root filaments. In the second test, three submaximal levels of stimulation were applied at eight muscle lengths. EMG signals were obtained using surface and wire electrodes, and force was measured using a strain transducer. For most muscle lengths, the relationships between integrated EMG and mean force obtained using wire and surface electrodes were sigmoid with a linear intermediate region. The effects of muscle length on EMG signals were likely to be associated with movement of the recording electrodes relative to each other and to the active motor units. Mean forces increased with increasing muscle length and with increasing levels of stimulation. Mean force-length relationships obtained using submaximal stimulation were not simply scaled down versions of the force-length relationship obtained using supramaximal stimulation of the soleus nerve, but appeared to be shifted towards longer muscle lengths.