Use of genomic analysis of varicella-zoster virus to investigate suspected varicella-zoster transmission within a renal unit

BACKGROUND

The source of hospital-acquired chickenpox infection may be presumed from a known exposure, but has not been previously proven using genomic analysis.

OBJECTIVE

Investigation of suspected VZV transmission was done using single nucleotide polymorphism genomic analysis.

STUDY DESIGN

Comparison was made of viral isolates from two patients with chickenpox on the same ward who were not known to have had direct contact.

RESULTS

An identical genotype in the variable R1 region of the VZV was isolated from the two patients.

CONCLUSION

Inapparent hospital-acquired transmission was the most likely route of infection.

Performance of a time-resolved fluorescence immunoassay for measuring varicella-zoster virus immunoglobulin G levels in adults and comparison with commercial enzyme immunoassays and Merck glycoprotein enzyme immunoassay

Highly sensitive and specific, quantitative assays are needed to detect varicella-zoster virus (VZV) immunoglobulin G in human sera, particularly for determining immune status and response following vaccination. A time-resolved fluorescence immunoassay (TRFIA) has been developed, and its performance was compared to that of two commercial enzyme immunoassays (EIAs) and Merck glycoprotein EIA (gpEIA). The TRFIA had equivalent sensitivity (97.8%) and high specificity (93.5%) in relation to gpEIA. A commercial (Behring) EIA compared favorably with TRFIA in terms of sensitivity (98.4%) but had lower specificity (80.7%). Another commercial EIA (Diamedix) had high specificity (97.1%) but low sensitivity (76.4%) compared to TRFIA if equivocal test results were treated as negative for VZV antibody. A novel feature of the TRFIA was that the cutoff was generated using population mixture modeling and was expressed in mIU/ml, as the assay was calibrated using the British standard VZV antibody.

Tumour necrosis factor alpha inhibitors in the treatment of childhood uveitis

OBJECTIVE

To describe the efficacy of anti-TNF-alpha agents in the treatment of childhood uveitis.

METHODS

We performed a retrospective chart review of all children with uveitis treated with TNF-alpha blockers at The Hospital for Sick Children, Toronto.

RESULTS

Twenty-one children with uveitis were treated with the anti-TNF-alpha agents etanercept (11 patients) and infliximab (13 patients), resulting in 24 treatment courses. All patients had persistently active uveitis despite treatment with at least one standard immunosuppressive drug before the start of anti-TNF-alpha therapy. Six of 21 patients (29%) had idiopathic uveitis. In the other 15 patients, the underlying disease was juvenile idiopathic arthritis in 12 (57%), Behçet disease in two (9%) and sarcoidosis in one (5%). Response to etanercept treatment was good in 27%, moderate in 27% and poor in 45% of patients. Response to infliximab treatment was good in 38%, moderate in 54% and poor in 8% of patients. The difference in the percentage of patients with a moderate or good response was statistically significant (P = 0.0481). We also observed a lower rate of complications, such as new-onset or worsening glaucoma or cataract in the infliximab-treated group.

CONCLUSION

Anti-TNF-alpha treatment was beneficial in a high percentage of patients with childhood uveitis refractory to standard immunosuppressive treatment. Infliximab resulted in better clinical responses with less ocular complications than etanercept.

European porphyria initiative (EPI): a platform to develop a common approach to the management of porphyrias and to promote research in the field

Porphyrias are uncommon inherited diseases of haem biosynthesis for which the diagnosis and treatment varies in individual countries. Despite the existence of guidelines recommended by porphyria experts concerning the diagnosis and management of the acute porphyrias, and of specialist centres in most European countries, many clinicians still do not apply these guidelines. The European Porphyia Initiative (EPI) network was formed in 2001 in order to compare experience among countries to attempt to develop a common approach to the management of the porphyrias, particularly concerning recommendation of safe and unsafe drugs, and to facilitate international collaborative clinical and biological research. The main achievements of EPI during this period have been: * Drafting and agreeing to consensus protocols for the diagnosis and management of acute hepatic porphyrias. * Creation of a multilingual website, particularly focusing on guidelines for common prescribing problems in acute porphyria and on providing information for patients that is now available in 10 languages: (www.porphyria-europe.org). EPI's current objectives are to develop the EPI platform, expand to new countries, extend to non-acute porphyrias and design European research and clinical trials in porphyria. The project will focus on: 1. Setting up a European laboratory external quality assurance scheme (EQAS) for biochemical and molecular investigations and their interpretation 2. Establishing a consensus drug list in collaboration with the Nordic porphyria network 3. Improving patient counseling 4. Developing large multi-centre, multi-national research projects. Due to the rarity of the porphyrias, it would be very difficult for any one country to provide this data with a sufficient number of patients and within a reasonable timescale. The progress achieved will facilitate improvements in the treatment and development of new therapeutic strategies. It will set a pattern for establishing, and subsequently harmonising, between countries best clinical practice for a rare but important group of diseases, and will help to develop the optimal therapy and ensure its cost effectiveness.

The effectiveness of treating juvenile dermatomyositis with methotrexate and aggressively tapered corticosteroids

OBJECTIVE

Childhood dermatomyositis (DM) is often a chronic disease, lasting many years. It has traditionally been treated with long-term corticosteroid therapy; side effects are often seen. For more than a decade, methotrexate (MTX) has been safely used for the treatment of juvenile arthritis. Here, we report use of MTX as first-line therapy for DM, along with aggressively tapered corticosteroids, in an attempt to reduce treatment-related side effects.

METHODS

We studied an inception cohort of 31 children with DM who were rigorously followed up in our myositis clinic, and compared them with a control group of 22 patients with incident cases of juvenile DM who received treatment just before we instituted a policy of first-line therapy with MTX. The mean starting dosage of MTX in the study group was 15 mg/m(2)/week.

RESULTS

Both groups had similar improvement in strength and physical function; however, the median time during which patients in the study group received corticosteroids was 10 months, compared with 27 months for controls (P < 0.0001). As a result, the cumulative prednisone dose in the study group was approximately half that in the control group (7,574 mg versus 15,152 mg; P = 0.0006). The study group had greater height velocity during the first year of treatment and a smaller increase in the body mass index over the first 2 years. In the control group, the relative risk of cataracts developing was 1.95 (95% confidence interval 1.05-4.17). Side effects of MTX were rarely observed.

CONCLUSION

Use of MTX in conjunction with an aggressively tapered course of prednisone may be as effective as traditional long-term corticosteroid therapy for children with DM, while decreasing the cumulative dose of corticosteroids.

Single agent versus combination chemotherapy for metastatic breast cancer

BACKGROUND

It is commonly thought that combining chemotherapy agents for treating women with metastatic breast cancer will result in regimens that are more active, offer superior tumour response rates with more time before progression and improve overall survival. However, it is not known whether giving patients more intensive chemotherapy regimens (judged according to some measure eg dose, dose intensity, response rate, or toxicity) results in better health outcomes. One way to investigate the effect of more versus less-intensive chemotherapy is to compare regimens containing a single drug (and hence possibly less active treatment) with regimens containing a greater number of drugs (and hence possibly more active but more toxic), even when adjustments are made to dosages or schedules to account for toxicity.

OBJECTIVES

To compare use of single chemotherapy agents with regimens containing a combination of agents for the treatment of metastatic breast cancer.

SEARCH STRATEGY

The Specialised Register maintained by the Editorial Base of the Cochrane Breast Cancer Group was searched on 2nd May 2003 using the codes for "advanced breast cancer", "chemotherapy". Details of the search strategy applied by the group to create the register, and the procedure used to code references, are described in the group's module on The Cochrane Library.

SELECTION CRITERIA

Randomised trials comparing single agent chemotherapy with combination therapy in women with metastatic breast cancer.

DATA COLLECTION AND ANALYSIS

Data were collected from published trials. Studies were assessed for eligibility and quality, and data were extracted by two independent reviewers. Hazard ratios were derived for time-to-event outcomes where possible, and a fixed effect model was used for meta-analysis. Response rates were analysed as dichotomous variables. Toxicity and quality of life data were extracted where present.

MAIN RESULTS

Thirty seven eligible trials were identified of which 28 had published time-to-event data. The quality of randomisation was generally not described. Data, based on an estimated 4220 deaths in 5707 women, show a modest advantage for combination chemotherapy regimens compared with single agents with a hazard ratio (HR) for overall survival of 0.88 (95% CI=0.83-0.94, P<0.0001) and no evident heterogeneity. Results are similar if the analysis is limited to trials in women receiving first-line chemotherapy. Combination regimens are favourably associated with time to progression (overall HR of 0.78 (95% CI=0.73-0.83, P<0.00001) and tumour response rates (OR 1.28, CI=1.15-1.42, P<0.00001) although significant heterogeneity was observed (P=0.002 and P<0.00001 respectively). This probably reflects the varying efficacy of the comparator regimens used in the trials. Women receiving combination regimens experienced a higher toxicity level for leukopenia, hair loss and nausea and vomiting compared with those receiving a single agent, which was statistically significant.

AUTHORS' CONCLUSIONS

Compared with single-chemotherapy agents, combination regimens show a statistically significant advantage for tumor response and time to progression in women with metastatic breast cancer, a modest improvement in overall survival and significantly worse toxicities.

Virtual outreach: a randomised controlled trial and economic evaluation of joint teleconferenced medical consultations

OBJECTIVES

To test the hypotheses that virtual outreach would reduce offers of hospital follow-up appointments and reduce numbers of medical interventions and investigations, reduce numbers of contacts with the health care system, have a positive impact on patient satisfaction and enablement, and lead to improvements in patient health status. To perform an economic evaluation of virtual outreach.

DESIGN

A randomised controlled trial comparing joint teleconsultations between GPs, specialists and patients with standard outpatient referral. It was accompanied by an economic evaluation.

SETTING

The trial was centred on the Royal Free Hampstead NHS Trust, London, and the Royal Shrewsbury Hospital Trust in Shropshire. The project teams recruited and trained a total of 134 GPs from 29 practices and 20 consultant specialists.

PARTICIPANTS

In total, 3170 patients were referred, of whom 2094 consented to participate in the study and were eligible for inclusion. In all, 1051 patients were randomised to the virtual outreach group and 1043 to standard outpatient appointments. The patients were followed 6 months after their index consultation.

INTERVENTIONS

Patients randomised to virtual outreach underwent a joint teleconsultation, in which they attended the general practice surgery where they and their GP consulted with a hospital specialist via a videolink between the hospital and the practice.

MAIN OUTCOME MEASURES

Outcome measures included offers of follow-up outpatient appointments, numbers of tests, investigations, procedures, treatments and contacts with primary and secondary care, patient satisfaction (Ware Specific Visit Questionnaire), enablement (Patient Enablement Instrument) and quality of life (Short Form-12 and Child Health Questionnaire). An economic evaluation of the costs and consequences of the intervention was undertaken. Sensitivity analysis was used to test the robustness of the results.

RESULTS

Patients in the virtual outreach group were more likely to be offered a follow-up appointment. Significant differences in effects were observed between the two sites and across different specialities. Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ENT and orthopaedics than in the other specialities. Fewer tests and investigations were ordered in the virtual outreach group, by an average of 0.79 per patient. In the 6-month period following the index consultation, there were no significant differences overall in number of contacts with general practice, outpatient visits, accident and emergency contacts, inpatient stays, day surgery and inpatient procedures or prescriptions between the randomised groups. Tests of interaction indicated that virtual outreach decreased the number of tests and investigations, particularly in patients referred to gastroenterology, and increased the number of outpatient visits, particularly in those referred to orthopaedics. Patient satisfaction was greater after a virtual outreach consultation than after a standard outpatient consultation, with no heterogeneity between specialities or sites. However, patient enablement after the index consultation, and the physical and psychological scores of the Short Form-12 for adults and the scores on the Child Health Questionnaire for children under 16, did not differ between the randomised groups at 6 months' follow-up. NHS costs over 6 months were greater for the virtual outreach consultations than for conventional outpatients, pound 724 and pound 625 per patient, respectively. The index consultation accounted for this excess. Cost and time savings to patients were found. Estimated productivity losses were also less in the virtual outreach group.

CONCLUSIONS

Virtual outreach consultations result in significantly higher levels of patient satisfaction than standard outpatient appointments and lead to substantial reductions in numbers of tests and investigations, but they are variably associated with increased rates of offer of follow-up according to speciality and site. Changes in costs and technological advances may improve the relative position of virtual consultations in future. The extent to which virtual outreach is implemented will probably be dependent on factors such as patient demand, costs, and the attitudes of staff working in general practice and hospital settings. Further research could involve long-term follow-up of patients in the virtual outreach trial to determine downstream outcomes and costs; further study into the effectiveness and costs of virtual outreach used for follow-up appointments, rather than first-time referrals; and whether the costs of virtual outreach could be substantially reduced without adversely affecting the quality of the consultation if nurses or other members of the primary care team were to undertake the hosting of the joint teleconsultations in place of the GP. Qualitative work into the attitudes of the patients, GPs and hospital specialists would also be valuable.

Silica-filled elastomer/methacrylate systems as soft liners

Denture soft lining materials are compliant cushions used at the oral tissue-denture interface. They are generally required to have sufficient compliance to redistribute mastication load, as well as an adequate modulus for long-term dimensional stability and control over the water uptake. This study investigated the effect of using silane treated fumed silica as a filler on the properties of experimental soft lining materials based on blends of isoprene-styrene (SIS) block co-polymer and mixtures of methyl methacrylate (MMA) and 1,6-hexandiol dimethacrylate (HDMA). The overall elastomer/monomer ratios were maintained, whereas the monomers ranged from 10 to 60% HDMA. The silica filler level was maintained at 10 wt% with respect to SIS. The properties investigated were the dynamic mechanical parameters of storage modulus (E') and tan delta as a function of temperature and the quasi-static mechanical parameters of ultimate tensile strength (UTS) and elongation to break (Eb) as well as absorption properties that were carried out in water and saline. In both unfilled and filled systems there was an increase in E' and a decrease in tan delta with an increase in HDMA. Silica addition tended to increase E' and substantially reduce tan delta in materials with less than 20% HDMA. UTS decreased with filler and HDMA content, however, Eb was greater for filled systems. Generally, in the long term, the water uptake decreased with increasing HDMA content and E'. The silanated silica further reduced the water uptake, indicating a cross-linking effect, thus increasing the restraining force on droplet growth. The uptake in saline was significantly reduced indicating an osmotically controlled uptake process.

A cationic lipid-formulated plasmid DNA vaccine confers sustained antibody-mediated protection against aerosolized anthrax spores

DNA vaccines provide an attractive technology platform against bioterrorism agents due to their safety record in humans and ease of construction, testing, and manufacture. We have designed monovalent and bivalent anthrax plasmid DNA (pDNA) vaccines encoding genetically detoxified protective antigen (PA) and lethal factor (LF) proteins and tested their immunogenicity and ability to protect rabbits from an aerosolized inhalation spore challenge. Immune responses after two or three injections of cationic lipid-formulated PA, PA plus LF, or LF pDNAs were at least equivalent to two doses of anthrax vaccine adsorbed (AVA). High titers of anti-PA, anti-LF, and neutralizing antibody to lethal toxin (Letx) were achieved in all rabbits. Eight or nine animals in each group were challenged with 100x LD(50) of aerosolized anthrax spores 5 or 9 weeks after vaccination. An additional 10 animals vaccinated with PA pDNA were challenged >7 months postvaccination. All animals receiving PA or PA plus LF pDNA vaccines were protected. In addition, 5 of 9 animals receiving LF pDNA survived, and the time to death was significantly delayed in the others. Groups receiving three immunizations with PA or PA plus LF pDNA showed no increase in anti-PA, anti-LF, or Letx neutralizing antibody titers postchallenge, suggesting little or no spore germination. In contrast, titer increases were seen in AVA animals, and in surviving animals vaccinated with LF pDNA alone. Preclinical evaluation of this cationic lipid-formulated bivalent PA and LF vaccine is complete, and the vaccine has received U.S. Food and Drug Administration Investigational New Drug allowance.

Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

OBJECTIVES

To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.

DESIGN

Cost consequences study alongside randomised controlled trial.

SETTING

Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.

PARTICIPANTS

3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.

MAIN OUTCOME MEASURES

NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.

RESULTS

Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001).

CONCLUSION

The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.

Follow-up of six blood donors highlights the complementary role and limitations of hepatitis C virus antibody and nucleic acid amplification tests

BACKGROUND AND OBJECTIVES

The purpose of this study was to analyse the follow-up results for six blood donors who screened positive for hepatitis C virus (HCV) by nucleic acid amplification technology (NAT) but were non-reactive in the primary antibody immunoassay (HCV NAT yield).

MATERIALS AND METHODS

Volunteer blood donations were screened, in parallel, for antibodies to hepatitis C virus (anti-HCV) and for human immunodeficiency virus (HIV)/HCV RNA using the Abbott PRISM HCV Chemiluminescent immunoassay (ChLIA) and the Chiron Procleix HIV-1/HCV RNA assays, respectively. NAT yield donor samples were further tested using supplemental assays, including an alternate HCV antibody enzyme immunoassay (EIA) (Abbott Murex anti-HCV Version 4), an immunoblot (Ortho RIBA-3 or Genelabs Diagnostics HCV Blot 3.0) and two alternative HCV NAT assays [Roche HCV Amplicor and an assembled HCV polymerase chain reaction (PCR)]. Five of the six donors were available for follow-up testing.

RESULTS

The six NAT yield donations were identified as constituents of 24-member minipools among 2,212,695 donations screened over the 28-month study period. All samples were positive when tested, undiluted, using the Roche Amplicor and assembled reverse transcription-polymerase chain reaction (RT-PCR) alternate NAT assays. One of the donors, subsequent to seroconversion, showed RNA levels that fluctuated above and below the limit of detection of the NAT screening assay. Three of the six were reactive on the secondary EIA and showed reactivity to the core c22(p) antigen by immunoblot at the index donation. Two others subsequently became reactive in the ChLIA prior to the EIA, showing reactivity against c100 and/or c33c antigens by immunoblot. The remaining donor became reactive in the ChLIA and EIA at the same time, showing RIBA reactivity against all of the following three peptides: c100; c33c; and c22(p).

CONCLUSIONS

This study demonstrated that at least five of six HCV NAT yield donors were in the pre- or early antibody seroconversion phase of infection. The observation that one yield donor demonstrated HCV RNA that fluctuated above and below the limit of detection of the primary NAT-screening assay supports the maintenance of both NAT and antibody screening for HCV. Follow-up testing of suspected yield donors revealed that the primary and alternate anti-HCV immunoassays had different performance characteristics, depending on the specificity of the donor's early anti-HCV response.

Predicting anxious response to a social challenge: the predictive utility of the social interaction anxiety scale and the social phobia scale in a college population

Trait anxiety is believed to be a hierarchical construct composed of several lower-order factors (Adv. Behav. Res. Therapy, 15 (1993) 147; J. Anxiety Disorders, 9 (1995) 163). Assessment devices such as the Social Interaction Anxiety Scale, the Social Phobia Scale (SIAS and SPS; Behav. Res. Therapy, 36 (4) (1998) 455), and the Anxiety Sensitivity Index (ASI; Behav. Res. Therapy, 24 (1986) 1) are good measures of the presumably separate lower-order factors. This study compared the effectiveness of the SIAS, SPS, ASI-physical scale and STAI-T (State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press (1970)) as predictors of anxious response to a social challenge (asking an aloof confederate out on a date). Consistent with the hierarchical model of anxiety, the measures of trait anxiety were moderately correlated with each other and each was a significant predictor of anxious response. The specific measures of trait social anxiety were slightly better predictors of anxious response to the social challenge than was either the ASI-physical scale or the STAI-T. The results provide evidence of the predictive validity of these social trait measures and some support for their specificity in the prediction of anxious response to a social challenge.

Family Caregivers' Motives for Helping Scale derived from motivation-to-help theory

The literature does not contain a measure of family caregivers' motives for helping provide daily complex home care. Such a measure will permit nurses to assess and provide interventions specific to each caregiver's motivation for helping. The purpose of this study was to apply Batson's empirically derived helping pathway theory to the measurement of caregiver motives for helping and develop a short form that does not add to the burden of caregiving. A Principal Components factor analysis (N = 93) of Family Caregivers' Motives for Helping Scale is used. Criterion-related validity is ascertained using a triangulated, independent validation procedure with qualitative data from a subsample (N = 41). Subsample subjects' interview data were categorized, based on Batson's theoretical pathway definitions, by coders blinded to caregiver Motives for Helping Scale scores. Three of Batson's four helping pathways (reward seeking, altruism, and punishment-avoidance) were extracted during factor analysis. This three-factor solution explained 66.6% of the variance and was confirmed by a 97% agreement between three of Batson's pathways and caregivers' helping motive score. The content analyses of the descriptive interview data also coincide with the 3-factor solution. The scale items representing Batson's fourth helping pathway, distress reaction, were not retained due to cross loading. The Family Caregivers' Motives for Helping Scale accurately measures three of four theoretically derived motivations for helping another. The scale should be reanalyzed in a larger sample of caregivers. Aligning nursing interventions to caregiver motives for helping can provide reinforcement for caregivers and potentially enhance home care outcomes.

Development of butyl elastomer/methacrylate monomer systems as denture soft lining materials

Previous studies have shown elastomer/methacrylate monomer formulations to have good strength; however, water uptake was high and they also suffered from oxidation. This study has looked at the use of three different butyl elastomers, well known for their oxidation resistance, butyl (PB), chlorobutyl (PCB) and bromobutyl (PBB). The tensile and water uptake properties of the three elastomers gelled with ethyl hexyl methacrylate containing 1% ethylene glycol dimethacrylate and 1% lauryl peroxide (5+ formulation from previous studies) were studied. Water uptake of the pure elastomers was also measured. Tensile strengths were low (PCB5+ = 3.09+/-0.12 MPa and PBB5+ = 3.90+/-0.36 MPa); however, elongation to break values were high (PCB5+ = 797+/-17% and PBB5+ = 599+/-13%). Water uptake was high and protracted with none of the formulations reaching equilibrium. The PCB5+ had the highest uptake (approximately 6% at 203 days) with that for PBB5+ and PB5+ at a similar level (approxiamtely 4% at 203 days). None of the materials showed any sign of oxidation. The PBB proved to be the most suitable of the three elastomers for further development in soft lining formulations.

Progenitor cells from patients with advanced phase chronic myeloid leukaemia respond to STI571 in vitro and in vivo

STI571 targets p210(BCR-ABL) in chronic myeloid leukaemia (CML). In vitro, STI571 reduces self-replication (replating ability) by chronic-phase CML CFU-GM. Here, we studied CFU-GM in advanced-phase (accelerated and blast crisis) CML. The numbers and self-replication of CFU-GM in advanced phase were greater than in the chronic phase. Self-replication by CFU-GM from advanced phase patients was reduced by STI571 or IFN alfa to the same extent as in the chronic phase. The reduced replating ability induced by STI571 correlated with that induced by IFN alpha (r=0.73). STI571 treatment in vivo also reduced replating ability and the numbers of CFU-GM/ml of blood.

Application of a PCR assay to enhance the detection and identification of Tritrichomonas foetus in cultured preputial samples

The traditional diagnostic test for Tritrichomonas foetus involves collection of preputial or vaginal samples followed by culture in a growth media and microscopic examination. Recently, polymerase chain reaction (PCR) techniques have been described for use as a diagnostic assay. The objective of this study was to evaluate a previously described PCR assay for detecting T. foetus in cultured preputial material. The detection limits of the assay for T. foetus organisms in a growth medium, in samples prepared from washing microscope slides, and in preputial material cultured in a growth medium were determined. Preputial samples were collected from 13 bulls uninfected with T. foetus. The PCR assay was able to detect 5 T. foetus organisms in the growth medium and the cultured preputial material. Amplification products were obtained from samples prepared from washes of microscope slides containing as few as 3 visualized organisms. The PCR assay was able to detect organisms in culture at a lower concentration than was possible by direct microscopic examination. This low detection limit may allow the PCR assay to be used to enhance the sensitivity of the current diagnostic test. In addition, the assay could be used to confirm the identification of T. foetus organisms observed by direct microscopic examination when other confirmation techniques, such as staining and phase microscopy, are not practical.

Prevention of bone loss and fracture after lung transplantation: a pilot study

BACKGROUND

Osteoporotic fracture is a significant source of morbidity after lung transplantation. Therapies to prevent posttransplant fracture are largely untested among lung transplant recipients.

METHODS

In this prospective uncontrolled study, lung transplant referrals were assessed for bone health with metabolic, radiographic, and bone mineral density measurements. Transplant recipients were treated with an antiresorptive regimen that included a bisphosphonate starting before or after transplantation. One year after transplantation, the fracture rate and bone density of patients in each group were reassessed and compared to historical controls. Between January 1996 and August 1999, 45/50 (90%) lung transplant referrals underwent bone health assessment. Transplant candidates received calcium, vitamin D, and hormone replacement therapy as indicated for hypogonadism. After July 1998, bisphosphonate therapy was added for candidates with osteopenia or osteoporosis (T score <1). After transplantation, all patients received 90 mg of pamidronate i.v. every 12 weeks, regardless of pretransplant bone density. Radiologic evaluation was performed for clinical suspicion of fracture. Bone density was remeasured 1 year after transplantation.

RESULTS

Most transplant referrals suffered from osteopenia or osteoporosis, and 29% of transplant referrals had prevalent vertebral compression fractures. Hypogonadism was untreated in 50% of men and 20% of women, and 15% of patients had hypovitaminosis D. Of the 21 patients assessed 1 year after transplantation, new fractures occurred in 4% of these patients. Lateral lumbar spine and hip bone density remained stable or improved in 65% and 86% of patients, respectively. Most of those who lost bone density had started bisphosphonate therapy after transplantation.

CONCLUSIONS

Antiresorptive therapy with a bisphosphonate decreases the fracture rate and preserves bone mass 1 year after lung transplantation. In end-stage lung disease patients with osteopenia or osteoporosis, bisphosphonate therapy should be initiated before transplant surgery is contemplated.

Identification of four new translocations involving FGFR1 in myeloid disorders

The 8p11 myeloproliferative syndrome (EMS) is associated with three translocations, t(8;13)(p11;q12), t(8;9)(p11;q33), and t(6;8)(q27;p11), that fuse unrelated genes (ZNF198, CEP110, and FOP, respectively) to the entire tyrosine kinase domain of FGFR1. In all cases thus far examined (n = 10), the t(8;13) results in an identical mRNA fusion between ZNF198 exon 17 and FGFR1 exon 9. To determine if consistent fusions are also seen in the variant translocations, we performed RT-PCR on four cases and sequenced the products. For two patients with a t(8;9), we found that CEP110 exon 15 was fused to FGFR1 exon 9. For two patients with a t(6;8), we found that FOP exon 5 (n = 1) or exon 7 (n = 1) was fused to FGFR1 exon 9. To determine if FGFR1 might be involved in other myeloid disorders with translocations of 8p, we developed a two-color FISH assay using two differentially labeled PAC clones that flank FGFR1. Disruption of this gene was indicated in a patient with a t(8;17)(p11;q25) and Ph-negative chronic myeloid leukemia in association with systemic malignant mast cell disease, a patient with acute myeloid leukemia with a t(8;11)(p11;p15), and two cases with T-cell lymphoma, myeloproliferative disorder, and marrow eosinophilia with a t(8;12)(p11;q15) and ins(12;8)(p11;p11p21), respectively. For the patient with the t(8;11), the chromosome 11 breakpoint was determined to be in the vicinity of NUP98. We conclude that 1) all mRNA fusions in EMS result in splicing to FGFR1 exon 9 but breakpoints in FOP are variable, 2) two-color FISH can identify patients with EMS, and 3) the t(8;17)(p11;q25), t(8;11)(p11;p15), t(8;12)(p11;q15), and ins(12;8)(p11;p11p21) are novel karyotypic changes that most likely involve FGFR1.

Isoprene-styrene copolymer elastomer and tetrahydrofurfuryl methacrylate mixtures for soft prosthetic applications

Novel elastomer/methacrylate systems have been developed for potential soft prosthetic applications. Mixtures of varying compositions of an isoprene-styrene copolymer elastomer and tetrahydrofurfuryl methacrylate (SIS/THFMA) formed one-gel systems and were heat cured with a peroxide initiator. The blends were characterised in terms of sorption in deionised water and simulated body fluids (SBF), tensile properties and viscoelastic parameters of storage modulus and tan delta, as well as glass transition temperatures using dynamic mechanical analysis (DMA). DMA data gave two distinct peaks in tan delta, a lower temperature transition due to the isoprene phase in SIS and one at high temperature thought to be a combination of THFMA and the styrene phase in SIS. The tensile data showed a clear phase inversion within the mid range compositions changing from plastic to elastomeric behaviour. The sorption studies in deionised water showed a two stage uptake with an initial Fickian region that was linear to t 1/2 followed by a droplet growth/clustering system. The slope of the linear region was dependent on the composition ratio. The extent of overall uptake was osmotically dependent as all materials equilibrated at a much lower uptake in SBF. The diffusion coefficients were found to be concentration dependent.

Blends of isoprene-styrene/methacrylate monomer systems as denture soft lining material

This work further develops the concept of using an elastomer gelled with methacrylate monomers to produce a methacrylate-based soft lining material without the use of a plasticizer. An isoprene-styrene (SIS) block copolymer was mixed with methyl methacrylate (MMA) and 1,6-hexandiol dimethacrylate (HDMA). The HDMA was used as a cross-linking agent. The elastomer/monomer ratios were maintained at 50/50 whereas the monomers ranged from 0 to 100%) HDMA. Mechanical properties and water absorption/desorption characteristics were used to assess the effect of varying the monomer compositions. The results indicated that phase separation took place, in particular at high HDMA content. This significantly increased the Young's modulus and decreased the elongation to break. Generally, the water uptake tended to decrease with increasing HDMA content, reflecting the effect of modulus. Second absorption cycles gave higher uptake values compared to the first. Formulations with a high amount of HDMA gave materials with modulus values too high for soft lining applications. This suggests that the optimum formulation requires a compromise between modulus and water uptake.

Regions in the carboxy terminus of alpha-bENaC involved in gating and functional effects of actin

Gating differences occur between the alpha-subunits of the bovine and rat clones of an amiloride-sensitive epithelial Na+ channel (ENaC). Deletion of the carboxy terminus of bovine alpha-ENaC (alpha-bENaC) at R567 converted the gating properties to that of rat alpha-ENaC (alpha-rENaC). The equivalent truncation in alpha-rENaC was without effect on the gating of the rat homologue. The addition of actin to ENaC channels composed of either alpha-rENaC or alpha-bENaC alone produced a twofold reduction in conductance and an increase in open probability. Neither alpha-rENaC (R613X) nor alpha-bENaC (R567X) was responsive to actin. Using a chimera consisting of alpha-rENaC1-615 and alpha-bENaC570-650, we examined several different carboxy-terminal truncation mutants plus and minus actin. When incorporated into planar bilayers, the gating pattern of this construct was identical to wild-type (wt) alpha-bENaC. Premature stop mutations proximal to E685X produced channels with gating patterns like alpha-rENaC. Actin had no effect on the E631X truncation, whereas more distal truncations all interacted with actin, as did wt alpha-bENaC. Key findings were confirmed using channels expressed in Xenopus oocytes and studied by cell-attached patch-clamp recording. Our results suggest that the site of actin regulation at the carboxy terminus of the chimera is located between residues 631 and 644.

The effect of particle size on the gelation of tissue conditioners

Tissue conditioner materials comprise a methacrylate polymer powder, usually poly(ethyl methacrylate) (PEM), and a plasticiser that also contains ethanol. The aim of this study was to investigate the effect of ball milling the PEM on gelation time. PEM was used as received and after ball milling for 2, 4, 8 and 16 h. Particle size was measured in each case and gelation time at 37 degrees C when mixed with butyl phthalyl butyl glycollate (BPBG). Gelation time reduced with increasing milling time of the powder, however it was found that increase in the fines initially had a more significant affect than overall reduction in average particle size. The gelation time of unmilled and 16 h milled PEM were also measured when mixed with BPBG and various levels of ethanol. Unmilled PEM with 4% ethanol had a gelation time of 13.5 +/- 2.0 min compared to 5.5 +/- 1.0 min for the 16h milled PEM which was similar to that for the commercial material, Viscogel (6.0 +/- 1.0 min). Ball milling the PEM reduces the level of ethanol required to produce a clinically acceptable gelation time.

Point mutations in the post-M2 region of human alpha-ENaC regulate cation selectivity

We tested the hypothesis that an arginine-rich region immediately following the second transmembrane domain may constitute part of the inner mouth of the epithelial Na+ channel (ENaC) pore and, hence, influence conduction and/or selectivity properties of the channel by expressing double point mutants in Xenopus oocytes. Double point mutations of arginines in this post-M2 region of the human alpha-ENaC (alpha-hENaC) led to a decrease and increase in the macroscopic conductance of alphaR586E,R587Ebetagamma- and alphaR589E,R591Ebetagamma-hENaC, respectively, but had no effect on the single-channel conductance of either double point mutant. However, the apparent equilibrium dissociation constant for Na+ was decreased for both alphaR586E,R587Ebetagamma- and alphaR589E,R591Ebetagamma-hENaC, and the maximum amiloride-sensitive Na+ current was decreased for alphaR586E,R587Ebetagamma-hENaC and increased for alphaR589E,R591Ebetagamma-hENaC. The relative permeabilities of Li+ and K+ vs. Na+ were increased 11.25- to 27.57-fold for alphaR586E,R587Ebetagamma-hENaC compared with wild type. The relative ion permeability of these double mutants and wild-type ENaC was inversely related to the crystal diameter of the permeant ions. Thus the region of positive charge is important for the ion permeation properties of the channel and may form part of the pore itself.

The acoustic qualities of Bora vowels

Bora contains the vowel system /i e a o i w/, where /i/ is high, central, open, unrounded and /w/ is high, back, open, unrounded. A contrast between /i/ and /u/ is exceedingly rare in the languages of the world. An opposition between a central and a back vowel which are otherwise identical is theoretically significant since it shows that the binary feature [+/- back] is too weak to encode all phonological contrasts along the front/back dimension. However, previous analyses of languages containing such oppositions are based primarily on impressionistic transcriptions without instrumental confirmation. This study contributes to the debate by providing acoustic evidence supporting the minimal contrast between /i/ and /w/ in Bora. The results indicate that these phonemes have identical F1 values, but /i/ yields higher F2 and F3 measurements than /w/, in keeping with their reported difference in backness.

Development of novel elastomer/methacrylate monomer soft lining materials

An earlier study identified a formulation comprising a butadiene/styrene copolymer (PBS) gelled with ethyl hexyl methacrylate (5 + formulation) as a potential denture soft lining material. It had good mechanical properties but water uptake was high as a result of the presence of a separating agent. This study has compared the tensile and water absorption properties of four elastomers free from separating agent (three butadiene/styrene, HBS, EBS, SBS, and one isoprene/styrene, SIS) with those of PBS all using the 5 + formulation. HBS is emulsion polymerized; the others are solution polymerized. SIS5 + had the better tensile properties whereas HBS5 + had the lowest water uptake. All the other 5 + formulations had higher uptakes than PBS5 +, which is thought to be due to the presence of hydrophilic groups from the solution polymerization process. All materials showed some sign of oxidation. Emulsion polymerized elastomers are regarded as less suitable for medical uses than the solution polymerized alternatives. Of these, SIS5 + seems to be less prone to oxidation and has the better mechanical properties so was considered to be the most suitable material for further development.

Effective treatment of hyperhomocysteinemia in heart transplant recipients with and without renal failure

BACKGROUND

Elevated total plasma homocysteine (tHcy) levels have been associated with vascular disease and higher mortality in patients with coronary artery disease. Graft coronary disease is a major cause of mortality in long-term survivors of heart transplantation, and hyperhomocysteinemia may be one of its causes. The objectives of our study were to establish the effectiveness of a 3 stage homocysteine-lowering algorithm in a group of 84 heart transplant (HTx) patients and to evaluate the effect of renal function on the response to homocysteine-lowering therapy.

METHODS

Prospective treatment of 84 Htx patients (64 male; mean age, 48 +/- 13 years) with tHcy > 75th percentile consisted of a 3-stage treatment algorithm: Stage 1, folic acid (FA) 2 mg + vitamin (vit) B(12) 500 mcg daily; Stage 2, addition of vit B(6) 100 mg daily; Stage 3, increase FA to 15 mg daily. Serum creatinine (Cr) and tHcy levels were measured before treatment and 21 +/- 19 weeks after each stage of treatment.

RESULTS

All 3 stages of treatment significantly lowered mean tHcy from 22.4 +/- 16.3 (mean +/- SD) micromol/liter to 16.3 +/- 6.7 micromol/liter (p < 0.00001), from 17.6 +/- 6.1 micromol/liter to 15.2 +/- 5.3 micromol/liter (p < 0.0001), and from 16.8 +/- 5.2 micromol/liter to 15.6 +/- 5.3 micromol/liter (p < 0.05), respectively. The average reduction from baseline was 38%. Creatinine levels did not change significantly during the study period. Total plasma homocysteine levels decreased below the 75th percentile in 55% of patients, with Cr levels significantly lower in this group of patients (126 +/- 36 micromol/liter vs 182 +/- 65 micromol/liter, p < 0.00001). However, we found no significant relationship between % change in tHcy and baseline Cr.

CONCLUSIONS

In a group of 84 heart transplant patients with tHcy levels >75th percentile, treatment with FA and vit B(6) and B(12) according to a 3-stage algorithm resulted in statistically significant declines in mean tHcy levels. Overall, tHcy levels decreased 38%, with target tHcy levels <75th percentile achieved in 55% of the patients. The % change in tHcy was not related to Cr. Further studies are needed to correlate treatment of hyperhomocysteinemia with clinical endpoints, such as the time to development of transplant vasculopathy and long-term survival, and to define the most appropriate targets for therapy.

A new approach to monitoring exercise training

The ability to monitor training is critical to the process of quantitating training periodization plans. To date, no method has proven successful in monitoring training during multiple types of exercise. High-intensity exercise training is particularly difficult to quantitate. In this study we evaluate the ability of the session rating of perceived exertion (RPE) method to quantitate training during non-steady state and prolonged exercise compared with an objective standard based on heart rate (HR). In a 2-part design, subjects performed steady state and interval cycle exercise or practiced basketball. Exercise bouts were quantitated using both the session RPE method and an objective HR method. During cycle exercise, the relationship between the exercise score derived using the session RPE method and the HR method was highly consistent, although the absolute score was significantly greater with the session RPE method. During basketball, there was a consistent relationship between the 2 methods of monitoring exercise, although the absolute score was also significantly greater with the session RPE method. Despite using different subjects in the 2 parts of the study, the regression relationships between the session RPE method and the HR method were nearly overlapping, suggesting the broad applicability of this method. We conclude that the session RPE method is a valid method of quantitating exercise training during a wide variety of types of exercise. As such, this technique may hold promise as a mode and intensity-independent method of quantitating exercise training and may provide a tool to allow the quantitative evaluation of training periodization plans.

Randomized controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease

BACKGROUND

A randomised trial was performed on patients presenting to hospital with an exacerbation of chronic obstructive pulmonary disease (COPD) to compare outcomes in those managed at home with support with those admitted to hospital in the standard manner.

METHODS

Over an 18 month period all patients presenting to the Royal Infirmary of Edinburgh on weekdays (n=718) with a diagnosis of an exacerbation of COPD were assessed for inclusion in the trial. Patients with impaired level of consciousness, acute confusion, acute changes on radiography, or an arterial pH of <7.35 or with other serious medical or social reasons for admission were excluded. Patients randomised to home support were discharged with an appropriate treatment package (antibiotics, corticosteroids, nebulised bronchodilators and, if necessary, home oxygen). They were visited by a nurse the following day and thereafter at intervals of 2-3 days until recovery when they were discharged from follow up. Parallel observations were made on patients allocated to normal hospital admission up to the point of discharge. Patients in both groups were assessed at home eight weeks after the initial assessment.

RESULTS

Among weekday patients 353 (50%) were considered obligatory admissions, 140 (19%) were admitted because of co-morbidity, 17 (2%) because of poor social circumstances, and 24 (3%) did not consent to the trial. The remaining 184 (26%) were randomised (2:1) either to home support or to a standard hospital admission. The median time to discharge was 7 days for the home support group and 5 days for the admitted group (p<0.01); 25% of the home support group and 34% of the admitted group were readmitted before the final assessment at eight weeks (p>0.05). There were no significant differences between the groups in attendances by GPs and carers or in health status measured eight weeks after the initial assessment. Satisfaction with the service was good. The mean total health service cost per patient was estimated as 877 pounds sterling for the home support group and 1753 pounds sterling for the admitted group.

CONCLUSIONS

This study shows that home supported discharge is a well tolerated, safe, and economic alternative to hospital admission for a proportion of patients referred to hospital for admission for an exacerbation of COPD.

Efficient factorization with a single pure qubit and logN mixed qubits

It is commonly assumed that Shor's quantum algorithm for the efficient factorization of a large number N requires a pure initial state. Here we demonstrate that a single pure qubit, together with a collection of log 2N qubits in an arbitrary mixed state, is sufficient to implement Shor's factorization algorithm efficiently.

HCV prevalence in pregnant women in the UK

The objective of the study was to assess the prevalence and epidemiology of hepatitis C virus (HCV) infection in pregnant women in the North Thames region, and in the UK in general. Demographic data were linked to neonatal samples prior to anonymization and testing by anti-HCV EIA, and with RIBA 3 confirmation. Risk factors for maternal infection were explored. Area-specific seroprevalence rates were multiplied into population sizes to estimate HCV prevalence in pregnant women in the UK. A total of 241/126,009 samples were confirmed anti-HCV positive, and a further 40 were indeterminate, representing a seroprevalence of 0.19-0.22%; 51% of maternal HCV infections were in UK-born women (71% of the population), and 22% in women from continental Europe (5% of the population). Among European-born women, HCV prevalence was associated with birth in continental Europe, partner not being notified at birth registration, partner born in a different region to the mother, and inner city residence. Four of the 241 anti-HCV positive samples (1.7%) were also anti-HIV-1 positive. It was estimated that each year an estimated 1150 out of 730,000 pregnancies in the UK would involve a woman infected with HCV (uncertainty range 660-1850), a prevalence of 0.16% (0.09-0.25%). On the basis of reported rates of mother-to-child transmission of HCV, this would represent approximately 70 paediatric HCV infections per year.

The general practice perspective on cancer services in Lothian

OBJECTIVES

The aim of the present study was to obtain views from general practices about current and potential improvements to services for patients with suspected lung, large bowel, non-melanoma skin and breast cancer.

METHOD

A questionnaire study was carried out of 134 general practices within the Lothian Health Board boundary. Information was sought about referral choices, communication, quality of care, liaison between community and hospital, health promotion, treatment outcomes and palliative care. Main outcome measures were determinants of primary care referral behaviour and clinical investigation strategies, and perception of quality in secondary care and health promotion services.

RESULTS

Seventy-nine general practices (59%) returned completed questionnaires. One-fifth of practices maintained a cancer register, and 85% provide patient information about cancer prevention. Initial management was disease dependent. Most cases of suspected lung cancer, about half of suspected colorectal cancer cases and very few cases of suspected breast cancer were investigated in primary care before referral to hospital. Hospital referral depended on knowledge of local services. A minority of practices wanted referral guidelines. It was estimated that 92% of lung and breast cancer cases, 68% of colorectal cancers and 35% of skin cancers are seen within 4 weeks. Breast cancer care was rated more highly than that for other cancers. One-third ranked community nursing support as 'excellent' and 10-15% described it as 'fair' or 'poor'; 77% describe palliative care as 'excellent' or 'good'. Fifty-one percent believe that communication with hospital is 'excellent' or 'good'. Practices were sometimes unaware of the hospital's post-diagnosis management plan; communication was often too slow and practices often received 'poor' advice about symptom control. Eighty percent thought that hospital follow-up for breast, colorectal and lung cancer should be routine; 20% thought that it was indicated for non-melanomatous skin cancer.

CONCLUSIONS

Communication problems between primary and secondary sectors need to be tackled innovatively and the perceived quality variation in services addressed-perhaps by developing local guidelines. Practices would welcome further education about health promotion resources and cancer epidemiology.

A high diagnostic rate in older patients attending an integrated syncope clinic

OBJECTIVES

To describe the findings in the first year of an integrated syncope clinic for older patients and to review the published literature on "integrated" syncope clinics investigating older people.

DESIGN

Review of syncope clinic database and Medline search for relevant literature.

SETTING

Outpatient syncope clinics in two district hospitals in the same city.

PARTICIPANTS

Secondary referrals from the in- and outpatient population with recurrent unexplained presyncopal and syncopal symptoms.

RESULTS

The results of testing in 76 patients over the age of 60 years were available for analysis. A diagnosis was achieved in 67 (88%) of the patients with 76% of the diagnoses being cardiovascular in origin. The prevalence rates of neurocardiogenic syncope (32%) and carotid sinus syndrome (17%), however, differed from previously reported rates.

CONCLUSIONS

Evaluation of presyncopal and syncopal events in an "integrated syncope clinic" achieves a high diagnostic yield in older subjects.

Fusion of H4/D10S170 to the platelet-derived growth factor receptor beta in BCR-ABL-negative myeloproliferative disorders with a t(5;10)(q33;q21)

We have studied a patient who presented with clinical features suggestive of chronic myeloid leukemia in accelerated phase. BCR-ABL transcripts were undetectable by reverse transcription-PCR, but a novel reciprocal translocation, t(5;10)(q33;q21.2), was seen by standard cytogenetic analysis. Chromosome band 5q33 contains the gene encoding the platelet-derived growth factor beta receptor (PDGFbetaR), the receptor tyrosine kinase that is disrupted by the t(5;7), t(5;12), and t(5;14) in myeloid disorders, resulting in the fusion of PDGFbetaR to HIP1, TEL/ETV6, and CEV14, respectively. Southern analysis with PDGFbetaR cDNA revealed novel bands in patient but not control DNA after digestion with several restriction enzymes, indicating that this gene is also targeted by the t(5;10). Fluorescence in situ hybridization analysis of chromosome 5 indicated that a small inversion at 5q33 had taken place in addition to the interchromosomal translocation. The site of the chromosome 10 breakpoint fell within YAC 940e4. Because all PDGFbetaR fusions described thus far result in splicing to a common exon of this gene, we performed 5'-rapid amplification of cDNA ends PCR on patient RNA. Several clones were isolated in which PDGFbetaR fused in frame to H4/D10S170, a previously described ubiquitously expressed gene that is fused to the ret protein tyrosine kinase to form the PTC-1 oncogene in approximately 20% of papillary thyroid carcinomas. The presence of H4-PDGFbetaR chimeric mRNA in the patient was confirmed by reverse transcription-PCR; reciprocal PDGFbeta1R-H4 transcripts were not detected. We conclude that t(5;10)(q33;q21.2) is a novel translocation in BCR-ABL-negative chronic myeloid leukemia and that this abnormality results in an H4-PDGFbetaR fusion gene. This finding further strengthens the association between myeloproliferative disorders and deregulated tyrosine kinases.

Best place of care for older people after acute and during subacute illness: a systematic review

OBJECTIVES

To assess the evaluative research literature on the costs, quality and effectiveness of different locations of care for older patients.

METHODS

A systematic review of evaluative research from 1988 using CRD4 guidelines. Twenty-five databases were searched, using processes developed specially for this review. Library OPACS, the Internet and research registers were also searched for relevant material. The final stage of the review was confined to randomised and pseudorandomised trials. Studies were selected for review by pairs of researchers working independently who then met to reach a decision. Analysis was predominantly descriptive; simple pooled odds ratios were used to explore some outcomes.

RESULTS

Eighty-four papers from 45 trials were included. Firm conclusions were difficult to draw, except in relation to some outcomes for stroke units, early discharge schemes and geriatric assessment units. Few trials in this area have adequately addressed issues of patients' quality of life and costs to health services, social care providers, patients and their families.

CONCLUSIONS

Despite considerable recent development of different forms of care for older patients, evidence about effectiveness and costs is weak. However, evidence is also weak for longer-standing care models. A substantial service evaluation agenda emerges from this review. This study also raises questions about the usefulness of systematic review techniques in the area of service delivery and organisation.

Human T cell leukaemia/lymphoma virus infection in pregnant women in the United Kingdom: population study

OBJECTIVE

To assess the prevalence of human T cell leukaemia/lymphoma virus (HTLV) infection in pregnant women in the United Kingdom.

DESIGN

Population study.

SUBJECTS

Guthrie card samples from babies born in 1997-8. Samples were linked to data on mother's age and ethnic status and parents' country of birth and then anonymised.

SETTING

North Thames Regional Health Authority.

MAIN OUTCOME MEASURES

Presence of antibodies against HTLV in eluates tested by gelatin particle agglutination assay and results confirmed by immunoblot.

RESULTS

Of 126 010 samples tested, 67 had confirmed antibodies to HTLV (59 HTLV-I, 2 HTLV-II, 6 untyped) and six had indeterminate results. Seroprevalence was 17.0 per 1000 (95% confidence interval 9.2 to 28.3) in infants whose mothers were born in the Caribbean, 3.2/1000 (1.5 to 5.9) with mothers born in west and central Africa, and 6.8/1000 (3.1 to 12.9) in infants of black Caribbean mothers born in non-endemic regions. In infants with no known risk (both parents born in non-endemic regions and mother not black Caribbean) seroprevalence was 0.06-0.12 per 1000. Mother's country of birth, father's country of birth, and mother's ethnic status were all independently associated with neonatal seroprevalence. An estimated 223 (95% confidence interval 110 to 350) of the 720 000 pregnant women each year in the United Kingdom are infected with HTLV.

CONCLUSIONS

The prevalence of HTLV and HIV infections in pregnant women in the United Kingdom are comparable. The cost effectiveness of antenatal HTLV screening should be evaluated, and screening of blood donations should be considered.

Collection of Ph-negative progenitor cells from interferon responsive patients with chronic myeloid leukemia: effect of granulocyte-colony-stimulating factor mobilization

BACKGROUND AND OBJECTIVE

The observation that patients with chronic myeloid leukemia (CML) may relapse following stem cell transplantation because of Philadelphia positive cells contaminating the graft have led to a variety of strategies to reduce this contamination. This study investigate the feasibility of collective, Ph-re cells from patients with CML in chronic phase.

DESIGN AND METHODS

A total of 18 patients with chronic myeloid leukemia in chronic phase who had responded to varying degrees to treatment with interferon-a (IFN) were subjected to mobilization with granulocyte colony-stimulating factors and peripheral blood progenitor cell collection. Nine patients were in complete cytogenetic remission (CCR) and nine were partial responders. IFN was stopped 2 to 4 weeks before the procedure. G-CSF was given by subcutaneous injection once daily at a dose of 10 microg/kg.

RESULTS

Five patients underwent one collection procedure only, 10 underwent two procedures and 3 patients had three collections. The median number of nucleated cells (NC) per patient collected was 10.2 x 10(8)/kg (4.4-19.7) and the median number of CD34(+) cells was 2.5 x 10(6)/kg (0.4-9.4). Analyzable cytogenetic data were available for 26/34 (76%) leukapheresis procedures. The median percentage of Ph- negative metaphases for patients in CCR was 100% (73-100). Patients not in CCR had a higher level of Ph-positive cells in their collections (median 23%, range 0-79%, p=0.01). Of the nine patients in CCR, 8 had at least one apheresis from which progenitor cells were 100% Ph-negative; conversely, patients not in CCR had detectable Ph-positive cells in every collection. Four patients have undergone autologous stem cell transplantation.

INTERPRETATION AND CONCLUSIONS

It was possible to collect sufficient Ph negative progenitor cells from patients in CCR but collections from other patients contained significant numbers of Ph-positive cells.

Incidental treatment of nipple discharge caused by benign intraductal papilloma through diagnostic Mammotome biopsy

OBJECTIVE

The purpose of this study was to evaluate imaging-guided vacuum-assisted mammotome biopsy as a minimally invasive method of obtaining a satisfactory diagnosis and eliminating the bothersome symptoms in patients presenting with nipple discharge.

MATERIALS AND METHODS

Forty-nine women who presented with nipple discharge and who had final pathologic diagnoses of papillary lesions were retrospectively identified. Fifty-six lesions were biopsied in this group. The examinations included mammography, ductography, sonography, and, if possible, percutaneous biopsy. All lesions were centrally located and most were superficial. Of this study group, four patients with five lesions proceeded to sonographically guided automated core biopsy, and 38 patients with 44 intraductal lesions identified by sonography advanced to sonographically guided biopsy with an 11-gauge mammotome probe. One patient underwent stereotactic 11-gauge mammotome biopsy. Patients not advancing to sonographically guided biopsy were those with masses either in the nipple or nipple-areolar complex (five patients), one patient with no identifiable lesion at sonography, and one directly referred for open surgical biopsy.

RESULTS

In all biopsied patients, satisfactory tissue for diagnosis was obtained. In patients biopsied with the mammotome probe, follow-up at a mean time of 13 months revealed resolution of the presenting problematic discharge in 97.2% of patients. Complications were mild and infrequent. Only one of 50 percutaneously biopsied lesions was not benign and required subsequent surgery.

CONCLUSION

Papilloma excision with percutaneous biopsy allows safe and accurate tissue analysis and a high probability of terminating the symptomatic nipple discharge.

Comparison of growth rates of Tritrichomonas foetus isolates from various geographic regions using three different culture media

The growth rates of 16 isolates of Tritrichomonas foetus from three distinct geographic regions were investigated in modified Diamond's medium, liver infusion broth medium and a commercially available culture kit. While some differences in growth characteristics were detected for different isolates and in the three different media, all isolates grew. Trichomonads reached peak concentrations from an initial concentration of 10(4) trichomonads/ml on Days 2, 3 and 4 in modified Diamond's medium, on Days 2-6 (excluding CAPTF102) in the commercial culture kit and on Days 2-7 in liver infusion broth medium. Viable parasites were detectable for longer periods in liver infusion broth medium and the commercial culture kit than in Diamond's medium. Peak concentrations for isolates tended to be higher in modified Diamond's medium than in liver infusion broth medium or the commercial culture kit. Results show that these three media are suitable for the growth of all 16 T. foetus isolates from three continents and suggest that these media could be used effectively throughout the world.