'Relapse' of chronic active hepatitis--not always what it seems

Immune chronic active hepatitis is a disease notorious for its unpredictability. In a patient with chronic hepatitis who has already suffered relapses a search for a second cause of jaundice is not usually necessary. This report emphasises the essential role of liver biopsy.

Explaining variations in inpatient length of stay in the National Health Service

This paper seeks to explain variations in acute inpatient length of stay in the National Health Service in England. A model is proposed in which the length of stay is allowed to vary according to patient characteristics, the local supply of NHS care. the local pressure on NHS resources, other non-NHS health care supply factors, and local policy effects. Length of stay data are obtained from the 1991/1992 Hospital Episode Statistics. They are standardized for age, sex and broad specialty group, and are aggregated to the level of small areas with populations of about 10,000. Explanatory variables include socio-economic data from the 1991 Census of Population, health status data, waiting time data, measures of access to inpatient and GP services, and measures of local private health care provision. The paper finds that variability in length of stay is greatest in the over-65 age group. The most important determinants of variations in length of stay are access to NHS hospitals, access to private hospitals, waiting times for elective surgery, indicators of poverty, and indicators of the availability of informal care.

Association of low CYP3A activity with p53 mutation and CYP2D6 activity with Rb mutation in human bladder cancer

p53 and Rb gene mutations are intermediate biomarkers useful for the prediction of neoplastic progression in bladder cancers. Previously, we have shown that low CYP3A activity, measured by dapsone N-hydroxylation, and high CYP2D6 activity, assessed by debrisoquine 4-hydroxylation, were significant susceptibility risk factors in developing aggressive bladder cancer. However, no information is available about the relationship between drug/xenobiotic metabolizing enzyme activities and p53/Rb mutations that may suggest mechanisms of bladder carcinogenesis. We evaluated in vivo CYP3A activity by the dapsone recovery ratio (DPRR), CYP2D6 activity by the debrisoquine recovery ratio (DBRR), CYP2C19 activity by the mephenytoin R/S ratio (RSR), N-acetyltransferase activity by the monoacetyl dapsone to dapsone ratio and glutathione-S-transferase M1 (GSTM1) genotype by PCR. In immunohistochemical studies of bladder tumor tissue, over expression of p53 protein was detected with antibody pAb1801 and loss of Rb protein expression was evaluated with antibody PMG3-245 in patients with transitional cell carcinoma of the bladder. Low CYP3A activity was significantly associated with over expression of or mutated p53 protein (P < 0.05). High CYP2D6 activity (within the extensive metabolizer group) was significantly associated with loss of expression of or mutated Rb protein (P < 0.05). Positive p53 staining also predicted aggressive bladder cancer histopathology (P < 0.05, odds ratio 2.9), and the lowest tertile of DPRR predicted p53 positivity (P < 0.01, odds ratio 3.9 comparing means of lower tertile versus upper tertile of DPRR). These selective associations are consistent with the hypothesis that an environmental pro-carcinogen fails to be detoxified by CYP3A which may preferentially induce p53 mutations, whereas, an alternative pro-carcinogen that may be activated by CYP2D6, may selectively induce Rb mutations.

Cyclin D1 and prognosis in human breast cancer

We have used immunohistochemical staining to assess the expression of cyclin D1 in formalin-fixed sections of 345 breast carcinomas, dating back 20 years. Clinical follow-up data were available on all patients. Approximately 50% of the tumours showed excessive nuclear staining for cyclin D1 as compared with normal epithelium. Some tumours showed strong cytoplasmic staining in the absence of nuclear staining, and around 25% of the tumours were judged to be negative for nuclear cyclin D1. Contrary to expectations, moderate/strong staining for cyclin D1 was associated with improved relapse-free and overall survival relative to patients whose tumours stained weakly or negatively. Conversely, tumours that were considered negative for cyclin D1 staining had an adverse prognosis, and the poor outcome was further accentuated if the tumours were also oestrogen receptor-negative. A possible explanation for our findings is that tumours in which cyclin D1 levels are abnormally low may have sustained mutations in other genes, such as RBI and that it is this abnormality that has the more significant impact on survival from breast cancer.

Median charge of gonadotrophin isoforms in the pituitary gland and in the circulation of sheep fetuses from mid- to late gestation

The heterogeneity of LH and FSH in the sheep fetus was studied by determining the median charge of pituitary and circulating isoforms. Pituitary extracts from male and female fetuses at days 75, 95, 120 and 135 of gestation were subjected to agarose suspension electrophoresis. For all fetuses except the day 75 age group, the median mobility of the gonadotrophin isoforms in matching serum samples from the individual fetuses were also determined. LH and FSH in extracts, peripheral samples and column eluates were measured using sensitive and specific sandwich fluoroimmunoassays for ovine gonadotrophins. The median charge of pituitary LH became more basic (P < 0.001) with gestational age, whereas for pituitary FSH more acidic forms (P < 0.001) were present in the older groups. The female fetuses had more basic pituitary isoforms of LH than the males (P < 0.01) between days 95 and 135, and for FSH at day 75 (P < 0.05). In the matching serum samples, the median charge of the LH (P < 0.001) and FSH (P < 0.05) isoforms were more acidic than those in the pituitary gland. No significant effects of age or sex were detected in the median charge of the gonadotrophin isoforms in serum, but in a number of instances the median charge could not be determined due to low serum concentrations which affected the group sizes. These data show that in the sheep fetus LH and FSH are differentially regulated in qualitative as well as quantitative terms, and that the charge of fetal gonadotrophin isoforms changes according to the age and sex of the fetus.

The life so short, the craft so hard to learn: a model for post-basic education in palliative care

This paper seeks to review the available educational palliative care experiences at post-basic level and explores different possibilities for current and future programmes. Central to this review is the exploration of the values and beliefs that underpin educational practice, and the relationship of these to palliative care practice. There are gaps in espoused theory, and theory in the practice of both is of critical importance. We locate our own values and beliefs in the new paradigm of human inquiry and propose that this paradigm and its methodologies have a considerable contribution to make to the development of both palliative care education and practice.

Bilateral synovitis in symptomatic unilateral transient synovitis of the hip: an ultrasonographic study in 56 children

56 children with a clinical diagnosis of unilateral transient synovitis of the hip underwent bilateral sonographic assessment. On the anterior scan, the distance between the femoral neck and the fibrous joint capsule was measured. This distance, which we call the synovial capsular complex distance, was compared with age-dependent normal values. An increased distance was found in all 56 symptomatic hips (mean 10 mm, SD 1.8). This distance was also increased in 14 hips on the contralateral side (mean 8 mm, SD 1.6). An effusion was demonstrated in 53 symptomatic hips and in 8 hips on the contralateral side. These findings indicate that in one quarter of children with symptoms of unilateral transient synovitis the contralateral hip may have an increased synovial capsular complex distance due to synovial swelling or joint effusion, suggesting an asymptomatic synovitis. We therefore recommend a comparison of the synovial capsular complex distance on the symptomatic side with age-related normal values, in addition to a comparison with the asymptomatic hip.

Risk factors for ill-health in a remote desert-dwelling aboriginal community in Western Australia

BACKGROUND

Living in small, isolated groups may promote health for Aborigines if traditional lifestyles are followed, but overall health risks in such communities are inadequately documented.

AIM

To document health status of a remote Aboriginal community with reference to nutrition, cardiovascular risks, renal disease and infections and to identify areas where health might be improved.

METHODS

All residents of a small community in the Great Sandy Desert underwent medical examinations, anthropometry and measurement of blood pressure. Investigations included cholesterol, triglycerides, glucose, insulin, creatinine, lipoprotein (a), apolipoprotein E phenotype, angiotensin-converting enzyme genotype, urinalysis, stool microscopy (children), liver function tests and full blood examination.

RESULTS

Children (n = 26) were undernourished while 14% of adults (n = 51) were underweight, 22% overweight and 40% of women and 13% of men were obese with central obesity in 90% of women and 48% of men. Fifteen per cent of the group were hypertensive. Insulin levels were increased in 55% of subjects, total cholesterol in 21% and triglycerides in 56%, while HDL was decreased in 78%. Angiotensin-converting enzyme and apolipoprotein E typing and lipoprotein (a) did not suggest increased cardiovascular risk. Proteinuria was present in 39% of subjects, haematuria in 49% and definite or possible urinary tract infections in 30%. Faecal parasites were prevalent and a history of infections, including sexually transmitted diseases, was common.

CONCLUSIONS

Increased cardiovascular risk, nutritional disorders, renal disease and infections are major problems in this community which had relocated several years previously from a mission environment closer to western influences, including alcohol.

[Cardiology education in Norway--does it keep up with the needs?]

Despite an increase in the number of education positions for cardiologists in Norway in the late 1980s, there is felt to be a marked lack of sub-specialists in cardiology in most types of hospitals. A working group under the Norwegian Society of Cardiology has used a questionnaire in 1993, membership data from the Norwegian Society of Cardiology in 1994, a telephone query to all hospitals in the country, and data from the Norwegian Medical Association in 1995 to examine this apparent lack of specialists and the potentials for educating them. We were able to confirm a current lack of approximately 60 cardiologists. In addition, the capacity for education has been reduced and will not compensate for the predicted retirement of specialists from approximately year 2000. The capacity for educating cardiologists must be increased.

The use of hypothermia and circulatory arrest to control intraoperative bleeding from the inferior vena cava

Bleeding from the suprahepatic inferior vena cava (IVC) was encountered in a patient undergoing repeat liver resection for the fourth time due to a recurrence of colorectal liver metastases. Bleeding was observed from an IVC tear above the liver and it was not possible to control it with traditional clamping procedures including total vascular exclusion (a suprahepatic clamp). Hypothermia, cardioplegia, and circulatory arrest were all required to control the bleeding. The inferior vena cava was reconstructed with a pericardial patch. The patient recovered well and was discharged on the 14th postoperative day.

Erectile dysfunction in men with chronic medical illness

This study examined interrelationships of psychosocial variables found in a psychological evaluation for erectile disorder in 75 male veterans with chronic medical illness. Patients whose partners participated in the evaluation were compared with those whose partners were not involved, and agreement on measures between patients and partners was examined. Finally, a principal components analysis was performed to assess the primary dimensions underlying the variance in mental health and sexual functioning variables. Five factors were identified, accounting for 65.5% of the variance. Results of these analyses are discussed in order to obtain an understanding of the interrelationship between behavioral, psychological, and interpersonal variables in the onset and course of sexual dysfunction.

Mutation of putative branchpoint consensus sequences in plant introns reduces splicing efficiency

Intron lariat formation between the 5' end of an intron and a branchpoint adenosine is a fundamental aspect of the first step in animal and yeast nuclear pre-mRNA splicing. Despite similarities in intron sequence requirements and the components of splicing, differences exist between the splicing of plant and vertebrate introns. The identification of AU-rich sequences as major functional elements in plant introns and the demonstration that a branchpoint consensus sequence was not required for splicing have led to the suggestion that the transition from AU-rich intron to GC-rich exon is a major potential signal by which plant pre-mRNA splice sites are recognized. The role of putative branchpoint sequences as an internal signal in plant intron recognition/definition has been re-examined. Single nucleotide mutations in putative branchpoint adenosines contained within CUNAN sequences in four different plant introns all significantly reduced splicing efficiency. These results provide the most direct evidence to date for preferred branchpoint sequences being required for the efficient splicing of at least some plant introns in addition to the important role played by AU sequences in dicot intron recognition. The observed patterns of 3' splice site selection in the introns studied are consistent with the scanning model described for animal intron 3' splice site selection. It is suggested that, despite the clear importance of AU sequences for plant intron splicing, the fundamental processes of splice site selection and splicing in plants are similar to those in animals.

Evaluation of the home pad test in the investigation of female urinary incontinence

OBJECTIVE

To evaluate the use of the home pad test in the management of patients with urinary dysfunction with reference to feasibility, normal data, reproducibility, compliance and accuracy when compared to video urodynamics.

DESIGN

A prospective study to determine 1. the accuracy of weighing pads by healthcare workers compared to weighing by patients with a spring balance; 2. the effects of evaporation; 3. the pad weight increase in continent women; 4. the compliance over 194 tests in terms of acceptability and feasibility; 5. the reproducibility in 112 women for the 24 h and 48 h tests, 6. the comparison with video urodynamic studies in 149 patients.

SETTING

A London teaching hospital.

MAIN OUTCOME MEASURES

Coefficient of variation and mean deviation analysis were employed to determine the accuracy of measurement. Percentage changes in standardised wet pad weights over a period of 8 weeks were used to determine the rate of weight loss due to evaporation. The percentage of patients completing the test satisfactorily was documented. The increase in the weights of all pads worn during the test period was measured in continent volunteers and incontinent patients. Video urodynamic diagnoses were used as the Gold Standard for comparison.

RESULTS

Twelve perineal pads were weighed by 15 healthcare workers with a resulting coefficient of variation equal to 1.55% (standard error = 0.09%). The mean deviation between patient-measured pad weights and staff-measured weights was 49% (SD = 132%). Pads wetted with saline showed no difference in weight after 1 week and less than 5% change in weight after 8 weeks, with the upper 95% confidence limit of less than 10% loss. The mean pad weight increase over 48 h in continent women was 7.13 g (SD = 4.32 g) giving a 95% upper confidence level of less than 15 g. Compliance was reasonably high with 161 (83%) carrying out the test perfectly. Test-retest analysis of the 24 h and 48 h tests showed a strong relationship with correlation coefficients of 0.90 and 0.94 respectively. The reproducibility was also good, with differences as a percentage of the mean between the first and second test being 6.9% and 1.6% for the 24 h and 48 h tests respectively. There was good concordance when the urodynamic study data was compared with pad weight data in terms of incontinence compared with no incontinence (kappa = 0.65), but a high false positive rate was detected for the pads. When eight of these patients with a false positive pad test had repeat video urodynamic studies, six were found to have detrusor instability on the second study.

CONCLUSIONS

The home pad test combined with frequency volume chart documentation is an easy test to perform. It is quite robust and reasonably reproducible. This test should be added to complement the routine urodynamic tests and may have a role in detecting occult detrusor instability.

Antimicrobial use in long-term-care facilities

There is intense antimicrobial use in long-term-care facilities (LTCF), and studies repeatedly document that much of this use is inappropriate. The current crisis in antimicrobial resistance, which encompasses the LTCF, heightens concerns of antimicrobial use. Attempts to improve antimicrobial use in the LTCF are complicated by characteristics of the patient population, limited availability of diagnostic tests, and virtual absence of relevant clinical trials. This article recommends approaches to management of common LTCF infections and proposes minimal standards for an antimicrobial review program. In developing these recommendations, the article acknowledges the unique aspects of provision of care in the LTCF.

Hydrogel intracorneal lenses in aphakic eyes

BACKGROUND

The theoretical benefits of synthetic keratophakia over conventional corneal lamellar procedures are the elimination of donor concerns and superior refractive predictability. Additionally, synthetic material can be inspected for optical quality and power, and it can be sterilized. Furthermore, visual recovery should be more rapid since epithelium is not removed from the central part of the cornea and the need for keratocyte repopulation is eliminated.

OBJECTIVE

To present results on patients who received an intracorneal implant (Kerato-Gel, Allergan Medical Optics, Irvine, Calif) that was made from lidofilcon A, a glucose-permeable hydrogel with an equilibrium water content of 68%.

METHODS

The intracorneal implants were implanted in 35 adult patients for correction of aphakia. Inclusion criteria excluded patients with aphakia who were candidates for intraocular lenses.

RESULTS

A total of 19 patients were followed up through 2 years postoperatively. For 16 patients with 2-year postoperative refractive data, the average spherical equivalent was -0.63 +/- 2.07 diopters (D). At 2 years, 88% of patients were within +/- 3.00 D of plano and 50% were within +/- 1.00 D. the mean change in Snellen's line for corrected visual acuity was -3.25 lines at 2 years for all patients and -2.0 lines for a subgroup of five patients who were free of vision-limiting preoperative disease.

CONCLUSIONS

Results suggest that this intracorneal implant is well tolerated by the cornea and can provide predictable refractive results in patients with high-risk aphakia. Limitations of the procedure are uneven microkeratome resections, loss of best-corrected visual acuity, and irregular astigmatism in some patients. Although these data show good evidence of biocompatibility of the implant material, technical surgical progress is needed to advance this procedure into clinical therapeutic practice.