Managing health services: how administrative data and population-based analyses can focus the agenda

University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for providing answers to such questions as: which populations need more physician services? Which need fewer? Are high-risk populations poorly served or do they have poor health outcomes despite being well served? Does high utilization represent overuse or utilization related to high need? More specifically, this system provides decision-makers with the capability to make critical comparisons across regions and subregions of residents' health status, socioeconomic risk characteristics, and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and counties, utilization review within a single hospital, and longitudinal research on health reform. A particularly interesting application to planning physician supply and distribution is discussed. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.

The Biographical Personality Interview (BPI)--a new approach to the assessment of premorbid personality in psychiatric research. Part I: Development of the instrument

The Biographical Personality Interview (BPI) is a research instrument for the retrospective assessment of premorbid personality traits of psychiatric patients. Its construction is based on results of a series of investigations in which biographical data from psychiatric case notes were analysed with respect to premorbid personality traits. In order to avoid methodological shortcomings of the utilisation of clinical records, an interview technique was developed. It is applied by two independent, specially trained investigators who are kept "blind" regarding any clinical data of the subject under study. One of them has to conduct the interview of a clinically remitted patient and to provide an interview protocol, the other one has to rate personality traits from that protocol along a large series of purely descriptive items. Sum scores for six personality structures ("types") are calculated and the case is then assigned to the intra-individually dominating personality type according to the highest of these scores.

Marfan Database (third edition): new mutations and new routines for the software

The Marfan database is a software that contains routines for the analysis of mutations identified in the FBN1 gene that encodes fibrillin-1. Mutations in this gene are associated not only with Marfan syndrome but also with a spectrum of overlapping disorders. The third version of the Marfan database contains 137 entries. The software has been modified to accommodate four new routines and is now accessible on the World Wide Web at http://www.umd.necker.fr

Assessment of functional ability in patients with scleroderma: a proposed new disability assessment instrument

OBJECTIVE

To develop a simple assessment of functional ability in patients with scleroderma and to examine its reliability both as a patient self-administered instrument and when administered by a trained observer.

METHODS

An 11 item, 4 grade, functional assessment questionnaire was developed after extensive consultation with patients, physiotherapists (PT), and occupational therapists (OT) with the aim of including all functional areas of relevance. The instrument was self-administered by patients after an interval of 7 days. In the interval, the patients were assessed using the same instrument by direct observation from both a PT and an OT. Forty-seven patients with scleroderma, of varying severity, were recruited from 2 centers. Results were similar for both centers and data were pooled for analysis.

RESULTS

Agreement between the patients' first and 2nd assessment was good for all questions (estimated kappas 0.69 to 0.94) with no evidence of an order effect. Agreement was also good between therapists (estimated kappas 0.47 to 0.81). There was poor agreement between patients and therapists, with patients rating their disability substantially higher compared to the standardized therapist assessment.

CONCLUSION

This assessment schedule has high face and content validity and has excellent reliability both between trained therapists and within patients over a short time period. Its administration either as a self-report or by a therapist depends, in part, on the type of investigation undertaken.

The Biographical Personality Interview (BPI)--a new approach to the assessment of premorbid personality in psychiatric research. Part II: Psychometric properties

The Biographical Personality Interview (BPI) was applied to 179 subjects (158 psychiatric patients and 21 probands from the general population); 100 patients and 20 healthy controls served as a validation sample; the others had been interviewed during the training period or did not meet the inclusion criteria for the validation of the BPI. The acceptance of the interview was high, the inter-rater reliability of the ratings of premorbid personality structures ("types") varied between 0.81 and 0.88 per type. Concurrent validity of the typological constructs as assessed by means of the BPI was inferred from the intercorrelations of type scores and correlations of these scores with questionnaire data and proved to be adequate. Clinical validity of the assessment was indicated by statistically significant differences between diagnostic groups. Problems and further developments of the instrument and its application are discussed.

International variation in anesthesia care during cataract surgery: results from the International Cataract Surgery Outcomes Study

OBJECTIVES

To describe international variation in anesthesia care and monitoring during cataract surgery and to discuss its implications for cost and safety.

METHODS

A standardized questionnaire was sent to random samples of ophthalmologists in the United States, Canada, and Barcelona, Spain, and to all ophthalmologists in Denmark. The survey was conducted in 1993 and 1994. Certified ophthalmologists who had performed 1 or more cataract extractions in the previous year were eligible for enrollment.

RESULTS

The response rates were 62% in the United States (n=148), 67% in Canada (n=276), 70% in Barcelona (n=89), and 80% in Denmark (n=82). The anesthetic technique for cataract surgery varied significantly between sites (P<.001). Surgeons reported that retrobulbar blocks were used for 46% of the cataract extractions in the United States, 70% in Canada, 66% in Denmark, and 31% in Barcelona. In Barcelona, general anesthesia was used for 23% of the cataract extractions; it was used for less than 3% of the extractions at the other 3 sites. Peribulbar blocks or topical anesthesia was used for the remaining extractions. In the United States, Canada, and Barcelona, surgeons reported that vital functions were monitored during more than 97% of the extractions and anesthesia surveillance was used during more than 78% of the extractions. In Denmark, ophthalmologists reported that vital functions were monitored and anesthesia surveillance was used for 1% of the cataract extractions (P<.001).

CONCLUSIONS

Substantial international variation in anesthesia care and monitoring during cataract surgery was observed. The findings suggest a need for further research to determine whether less intensive monitoring is cost-effective.

Willingness to pay to shorten waiting time for cataract surgery

We interviewed persons who had recently been placed on a public waiting list for cataract surgery in Manitoba, Canada; Barcelona, Spain; and Denmark. The majority of the respondents were unwilling to pay higher taxes to reduce the length of the waiting list or to pay more out of pocket to have the surgery performed earlier in the private sector. Less than 2 percent actually had the surgery done in the private sector. We conclude that in spite of expressed public dissatisfaction with waiting lists in all three sites, a majority of the respondents did not support the actions that could have reduced their own wait.

Practices associated with cataract surgery in Canada: results of a national survey

OBJECTIVE

To examine Canadian ophthalmologists' reported practices related to cataract surgery.

DESIGN

Mailed questionnaire survey.

SETTING

Canada.

PARTICIPANTS

Random sample of 698 ophthalmologists from the mailing list of the Canadian Ophthalmological Society. Of the 528 eligible ophthalmologists 353 completed the questionnaire (response rate 67%). A total of 276 respondents were classified as cataract surgeons (performed at least one cataract operation in the preceding year [1992]) and were included in the study.

OUTCOME MEASURES

Reported use of preoperative ophthalmic tests, surgical technique, cataract anesthesia (including type of block and who administers it) and postoperative care.

RESULTS

Most of the preoperative tests examined either were so routine as to be done in almost all cases or were rarely done at all. A total of 52% of the respondents were identified as predominantly extracapsular cataract extraction surgeons (ECCE), 46% as predominantly phacoemulsification surgeons and 2% as predominantly intracapsular cataract extraction surgeons. Overall, 57% of the respondents reported high use of retrobulbar anesthesia, 18% reported high use of peribulbar anesthesia, and 0.7% reported high use of general anesthesia. The mean number of postoperative visits in the first 4 months after surgery was 4.25. The mean rate of Nd:YAG laser capsulotomy in the first year after cataract surgery was 17.9%; 91% of the respondents reported a rate less than 40%.

CONCLUSIONS

There seems to be limited use of nonessential preoperative ocular testing by Canadian cataract surgeons. Although ECCE remains the most common type of surgery performed, there appears to be a substantial number of surgeons trying phacoemulsification, and this will likely become the predominant technique in the near future. The self-reported practices of Canadian surgeons with relation to preoperative testing and postoperative follow-up appear to be consistent with the Clinical Practice Guideline for cataract surgery set by the US Agency for Health Care Policy and Research. However, variations in the number of postoperative visits and Nd:YAG capsulotomy rates merit further investigation.

Patients' acceptance of waiting for cataract surgery: what makes a wait too long?

The patient's perspective about waiting for elective surgery is an important consideration in the management of waiting lists, yet it has received little attention to date. This study was undertaken to assess the acceptability of personal waiting times from the perspective of patients, and to examine waiting time and patient characteristics associated with the perception that a wait for cataract surgery is too long. The international prospective study was conducted in three sites with explicit waiting systems: Manitoba, Canada; Denmark; and Barcelona, Spain. Patients over the age of 50 years were recruited consecutively from ophthalmologists' practices at the time of their enlistment for first-eye cataract surgery. Anticipated waiting time, opinions about personal waiting time, and patients' visual and health characteristics were identified by means of telephone interviews. The 550 patients interviewed at the time of enlistment for surgery anticipated waits varying from < 1 to 24 months. Clinical visual acuity measures were obtained from patients' ophthalmologists/cataract surgeons. Results indicated that anticipated waiting time was the strongest predictor of patients' tolerance of waiting for cataract surgery. Patient dissatisfaction increased with the duration of the anticipated wait. Patients in all three sites were accepting of waits of three months or less, and considered waits exceeding six months to be excessive. Response to waits between three and six months varied across study sites. Patients with low tolerance for waiting had greater self-reported difficulty with vision, as assessed by a Cataract Symptom Score and expressed trouble with vision. Patients' acceptance of waiting was not associated with clinical visual acuity measures or socio-demographic characteristics. The patient perspective on acceptability of waiting times for cataract surgery suggests that restricting waiting times to less than six months and preferably less than three months and utilizing self-reported measures of visual difficulty in prioritizing patients may contribute to improved management of waiting systems. Patients are more tolerant of their personal waiting times than responses to questions about waiting for elective surgery in general would indicate, and appear to accept waiting times that are longer than those identified as reasonable by specialists.

International applicability of the VF-14. An index of visual function in patients with cataracts

PURPOSE

There is increased recognition that a rigorous approach to functional assessment should complement the assessment of clinical status. The authors compare the reliability, validity, and responsiveness to clinical change of a visual function index (VF-14) in non-U.S. and in U.S. patients with cataracts.

DESIGN

An observational longitudinal study was performed.

PARTICIPANTS

One thousand four hundred seven first eye cataract surgery patients were recruited in four international sites: Manitoba (Canada), Denmark, Barcelona (Spain), and the United States.

INTERVENTION

Patients were evaluated before cataract surgery and at a 4-month postoperative follow-up visit. Patients completed the preoperative interview and the clinical examination (766 in the United States, 152 in Manitoba, 291 in Denmark, and 198 in Barcelona), and 91.3% of those (1284) also completed the 4-month postoperative follow-up interview and were evaluated postoperatively by an ophthalmologist.

MAIN OUTCOME MEASURES

The authors used the following measures: the visual function index (VF-14), the Sickness Impact Profile (SIP), global measures of patients' trouble and satisfaction with vision, and best-corrected visual acuity (VA) in each eye.

RESULTS

The VF-14 showed a high internal consistency reliability level in all sites (Cronbach's alpha coefficients > or = 0.84). Correlation of preoperative visual function index scores with the Vision-Related SIP was strong (r = -0.68 in non-U.S. and r = -0.57 in U.S. patients) and with VA in the eye with better vision was moderate (r = 0.40 and r = 0.27, respectively), the pattern of relationships being very similar among U.S. and non-U.S. patients. In patients with only first-eye surgery who reported that their initial trouble with vision had improved, the amount of change in visual function as assessed by the VF-14 (effect size) was large (1.01 for the non-U.S. patients and 1.17 for the U.S. patients).

CONCLUSIONS

The non-U.S. versions of the visual function index (VF-14) analyzed are as reliable, valid, and responsive to clinical change as the original U.S. version. These versions are appropriate for international studies of cataract patients outcomes and possibly in routine clinical practice.

A comparative anatomical and biochemical analysis in salsola (Chenopodiaceae) species with and without a Kranz type leaf anatomy: a possible reversion of C4 to C3 photosynthesis

Leaf anatomy was studied by light and electron microscopy and the leaf activities of RUBP carboxylase, PEP carboxylase, and malic enzyme were assayed in: Salsola australis and S. oreophila grown on the West Pamirs at 1800 m altitude; in S. australis grown on the East Pamirs at 3860 m; and in S. arbusculiformis grown in the Kisil-Kum desert in Middle Asia near 500 m. Carbon isotope fractionation ratio values also were measured on whole leaf tissue for 18 Salsola species field collected in these and other regions of the former USSR. S. australis leaves are cylindrical and in cross section exhibit a peripheral ring of mesophyll and then an inner ring of bundle sheath type cells; and its biochemical characteristics and deltaC values are typical of a C4 species of the NADP-malic enzyme malate-forming group. These traits were expressed independent of the plant growth altitude up to 4000 m. C4 type deltaC values were obtained in 14 of the Salsola species. Anatomical, structural, and biochemical features typical of the C4 syndrome were absent in S. oreophila and S. arbusculiformis. Four Salsola species, including these two, had C3-type deltaC values. Their cylindrical leaves in cross section exhibited two to three peripheral rings as layers of palisade parenchyma. Although their vascular bundles were surrounded by green bundle sheath cells, their organelle numbers were comparable to those in mesophyll cells. Neither bundle sheath cell wall thickenings nor dimorphic chloroplasts in two leaf cell types were observed. In S. oreophila, there was a high activity of RuBP carboxylase, but a low activity of C4 cycle enzymes. Interpretation of these data lends evidence to the hypothesis that a small group of C3 Salsola species, including S. oreophila, S. arbusculiformis, S. montana, and S. pachyphylla, arose as the result of a reversion of a C4 to a C3 type of photosynthetic CO2 fixation in the cooler climates of Middle Asia.

Wound management in patients with traumatic injuries

This case report describes the management of a patient with extensive impact injuries

Scrapie infection alters the membrane and synaptic properties of mouse hippocampal CA1 pyramidal neurones

1. Electrophysiological recordings using conventional intracellular and extracellular techniques were made from the CA1 region of the hippocampus of ME7 scrapie-infected mice in a brain slice preparation at specific stages during the incubation period of the disease and compared with data obtained from age-matched control animals. 2. Extracellular field EPSP recordings in the stratum radiatum showed a gradual increase in the effective stimulus threshold and a reduction in amplitude of the response 5 months after inoculation with scrapie. Terminal animals showed a complete loss of the field EPSP. 3. Intracellular recordings from CA1 pyramidal cells of scrapie-infected animals after 5 months showed that the Schaffer collateral-evoked EPSP was attenuated, the effective stimulus threshold was increased and the rise time was slower in slices from scrapie-infected mice than in age-matched control mice. Inhibitory potentials evoked by the same stimulus also appeared weaker in scrapie-infected mice at this time. 4. To determine if the mechanisms of transmitter release during low-frequency stimulation of the Schaffer collaterals were altered in scrapie-infected mice, paired-pulse experiments were performed, but failed to show any differences between cells from scrapie-infected and control animals. 5. Pyramidal cells from scrapie-infected mice showed depolarized resting potentials and an increased membrane resistance compared with age-matched control cells. 6. The majority of scrapie-infected cells were spontaneously active, showing both single spike and bursting activity. The observed bursting activity was abolished and the spontaneous discharge rate of infected cells was markedly reduced by removing the CA3 area from the slice. 7. The action potential of cells from scrapie-infected mice showed a faster falling phase and larger amplitude fast and medium after-hyperpolarizations (AHPs) than age-matched control cells. In response to depolarizing current pulses cells from infected tissue showed a loss of early spike frequency adaptation. 8. Morphological observations of biocytin-labelled neurones confirmed our recordings were from pyramidal cells and showed that CA1 cells from scrapie-infected mice after 5 months showed a marked loss of dendritic spines and an abnormal dendritic morphology that included the appearance of vacuolar swellings. 9. The data show that membrane and synaptic abnormalities of the CA1 pyramidal neurones develop around 5 months after intracerebral infection of the mouse hippocampus with ME7 scrapie.

International variation in ophthalmologic management of patients with cataracts. Results from the International Cataract Surgery Outcomes Study

OBJECTIVES

To describe international variation in the management of patients with cataacts in 4 health care systems and to discuss the potential implications for cost and utilization of services.

DESIGN

To characterize current clinical practice on patients with no coexisting medical or ocular conditions, a standardized questionnaire was sent to random samples of ophthalmologists in the United States (response rate, 82.5%), Canada (66.9%), and Barcelona, Spain (70.4%), and to all ophthalmologists in Denmark (80.1%). From the United States, 526 ophthalmologists who performed cataract surgery participated in the study; there were 276 from Canada, 89 from Barcelona, and 82 from Denmark.

RESULTS

Although in all 4 sites most surgeons reported that they performed A-scanning, fundus examination, and refraction routinely before surgery, significant crossnational variation was observed in preoperative ophthalmic and medical testing. While preoperative medical tests were virtually unused in Denmark, they were widely used in the other sites. A significantly higher proportion of the surgeons in the United States and Barcelona reported that they performed less than 100 extractions per year compared with surgeons in Canada and Denmark (P < .001). A significantly higher proportion of the surgeons in the United States and Canada were performing predominantly phacoextraction compared with surgeons in Denmark and Barcelona (P < .001). Both within and across sites, considerable variation in number of follow-up visits and postoperative tests was observed.

CONCLUSIONS

Significant international variation in the management of healthy patients with cataracts has been observed. If less intensive care is not associated with poorer outcomes, there is the potential for less costly care of patients with cataracts. Further research identifying the most cost-effective practices is needed.

Characterization of antinucleolar antibody reactivity in patients with systemic sclerosis and their relatives

OBJECTIVE

To study the prevalence and specificity of antinucleolar antibodies (ANoA) in patients with systemic sclerosis (SSc), their spouses, and their first-degree relatives, and to investigate whether SSc family members have greater frequency of ANoA than expected.

METHODS

The sera of 58 SSc probands, 4 first-degree relatives with SSc, 215 first-degree relatives without SSc, and 24 spouses were screened for ANoA by indirect immunofluorescence (IF), and nucleolar antigens were characterized by immunoprecipitation (IP) of 35S methionine labeled K562 cell extracts. Sera from 118 randomly chosen family members without SSc were separately compared with 120 age and sex matched blood donor controls.

RESULTS

Antinucleolar reactivity was detected by IF in 25 patients with SSc (40.3%), in 33 non-SSc relatives (15.3%), and in 4 spouses (16.7%). Twenty-four sera had autoantibodies to defined nucleolar antigens by IP (seven Pm-Scl, ten RNA polymerase (pol) I, four U3 RNP, three Th RNP), and all were from patients with SSc (38.7%). No serum had more than one type of nucleolar-specific autoantibody. Four sera had autoantibodies to topoisomerase I (topo I) and RNA pol II, one of which also recognized RNA pol I and RNA pol III. Antinucleolar IF was significantly more common in the unaffected first-degree relatives of patients with SSc (18.1%) than in controls (8.3%; p < 0.05). A small number of sera from both relatives and controls recognized bands by IP, none of which was identified as a SSc-specific autoantigen.

CONCLUSION

Although antinucleolar reactivity is more common in the first-degree relatives of patients with SSc than controls, SSc associated ANoA are only present in patients with the disease, and appear to be mutually exclusive.

Marfan Database (second edition): software and database for the analysis of mutations in the human FBN1 gene

Fibrillin is the major component of extracellular microfibrils. Mutations in the fibrillin gene on chromosome 15 (FBN1) were described at first in the heritable connective tissue disorder, Marfan syndrome (MFS). More recently, FBN1 has also been shown to harbor mutations related to a spectrum of conditions phenotypically related to MFS. These mutations are private, essentially missense, generally non-recurrent and widely distributed throughout the gene. To date no clear genotype/phenotype relationship has been observed excepted for the localization of neonatal mutations in a cluster between exons 24 and 32. The second version of the computerized Marfan database contains 89 entries. The software has been modified to accomodate new functions and routines.

Continuity of pediatric ambulatory care in a universally insured population

OBJECTIVE

To describe the prevalence of continuity of care over a 5-year period in a complete cohort of urban children universally insured for medical care provided under fee-for-service reimbursement.

METHOD

All children enrolled in the study were born to women living in metropolitan Winnipeg between July 1, 1987 and December 31, 1988 (N = 12,590). All ambulatory physician services for this group were enumerated from computerized administrative databases for the period from birth through 60 months. Continuity of care, defined as the proportion of total care provided by the most frequently seen physician or physician practice over time, was calculated for each child. Descriptive analyses include an examination of maternal and household characteristics associated with children receiving 80% or more of total ambulatory care from a single provider source.

RESULTS

From birth to 24 months, 51% of children received at least 80% of ambulatory visits from a single provider practice. This proportion of the children declined to 28% at 25 through 60 months. Children living in low-income neighborhoods had poorer continuity profiles. Other household factors associated with poor continuity included young maternal age, single maternal marital status, residential mobility, and inadequate maternal use of prenatal medical care. Households affiliated with pediatric practices had better continuity profiles than households affiliated with general medical practices.

CONCLUSION

Despite universal medical insurance, barriers to a longitudinally continuous relationship with a primary care provider remain in this setting. Although this study has emphasized the description of those barriers associated with household characteristics, there is evidence that factors related to the organization and delivery of medical care are also relevant.

A Cross-Task Comparison of False Belief Understanding in a Head Start Population

This research had two main goals: to compare different methods of assessing understanding of false belief and to extend the study of false belief to the population served by Project Head Start. Across two experiments the participants were ninety 3-, 4-, and 5-year-old children, drawn from low-income, primarily African-American families. Each child responded to a battery of false belief tasks that varied in the type of belief in question (contents tasks versus locations tasks), the target for the belief ascription (own belief versus other's belief), the method of presenting the reality information (visual versus verbal), and the presence or absence of a deception context. Performance was better on locations tasks than on contents tasks and among older children compared to younger children; the other comparisons resulted in smaller and less consistent effects. Despite the improvement with age, the level of performance fell short of that typically reported in the literature. Although correlations among tasks were significant, fewer than half of the children performed consistently across the problems.

Survival following the onset of scleroderma: results from a retrospective inception cohort study of the UK patient population

Scleroderma is a multisystem disease which in many populations is reported to have a substantially reduced survival. One problem with many of the published studies is the inclusion of patients with differing lengths of disease at baseline, with the possibility of left censorship bias. The aim was to determine the survival and its predictors in a cohort of scleroderma patients with new onset of disease. All 283 new patients referred to one of the authors (CMB) who had a reported disease onset after 1 January 1982 were studied. Detailed clinical and laboratory information at baseline and at 1 yr were extracted from the structured records. Vital status as at 1 December 1993 was determined using the UK's NHS Central Register. Expected numbers of deaths were obtained by applying local age and sex all-cause mortality rates. In total, there were 1871 person-years of follow-up with crude mortality rates of 3.9 and 2.6%/year, respectively, in males and females. The mortality rate remained approximately constant over the first 10 yr of follow-up. In comparison with expected survival, based on the age distribution of the cohort, there was an overall 4-fold increased mortality rate in this group which was higher in females [standardized mortality ratio (SMR) 4.6, 95% CI 3.2-6.2] than in males (SMR 3.2, 95% CI 1.8-5.0). Analysis of cause-specific mortality showed that 79% of the excess deaths were scleroderma related, but this proportion was substantially lower in males than in females (67% vs 83.9%). These data confirm the increased mortality rate associated with scleroderma, but these rates are lower than those reported from other centres. Females have a higher age-adjusted mortality which is reflected in the different pattern of mortality between the sexes.

Relapse prevention by means of paroxetine in ECT-treated patients with major depression: a comparison with imipramine and placebo in medium-term continuation therapy

In-patients with severe major depression were treated in the acute phase with electroconvulsive therapy (ECT) in combination with antidepressants. The drug treatment consisted of two randomized trials which were both extended into the post-ECT continuation phase. Patients with electrocardiological impairment were randomized to either 30 mg paroxetine daily or placebo under blind conditions. Patients without electrocardiological impairment were randomized to either 30 mg paroxetine daily or 150 mg imipramine daily. There was a high level of agreement between the Hamilton Depression Scale and the Melancholia Scale, demonstrating that the patients treated with ECT plus imipramine in the acute phase showed greater symptom reduction than those treated with ECT plus paroxetine. However, in the post-ECT phase paroxetine was superior to both imipramine and placebo in preventing relapse. Thus in the post-ECT phase 65% of the placebo-treated patients relapsed, compared to 30% of the imipramine-treated patients and 10% of the paroxetine-treated patients. The psychometric analysis of the Melancholia Scale in the continuation or post-ECT phase showed that relapsing patients displayed a pattern with lack of interests, impaired concentration, depressed mood and anxiety among the less severe symptoms (first-compartment symptoms). In other words, these symptoms represent the gate to full-blown depression (second-compartment symptoms). Serotonin-selective antidepressants such as paroxetine appear to be more effective in controlling the first-compartment symptoms.

A potent far-upstream enhancer in the mouse pro alpha 2(I) collagen gene regulates expression of reporter genes in transgenic mice

We have identified three DNase I-hypersensitive sites in chromatin between 15 and 17 kb upstream of the mouse pro alpha 2 (I) collagen gene. These sites were detected in cells that produce type I collagen but not in cells that do not express these genes. A construction containing the sequences from -17 kb to +54 bp of the mouse pro alpha 2 (I) collagen gene, cloned upstream of either the Escherichia coli beta-galactosidase or the firefly luciferase reporter gene, showed strong enhancer activity in transgenic mice when compared with the levels seen previously in animals harboring shorter promoter fragments. Especially high levels of expression of the reporter gene were seen in dermis, fascia, and the fibrous layers of many internal organs. High levels of expression could also be detected in some osteoblastic cells. When various fragments of the 5' flanking sequences were cloned upstream of the 350-bp proximal pro alpha 2(I) collagen promoter linked to the lacZ gene, the cis-acting elements responsible for enhancement were localized in the region between -13.5 and -19.5 kb, the same region that contains the three DNase I-hypersensitive sites. Moreover, the DNA segment from -13.5 to -19.5 kb was also able to drive the cell-specific expression of a 220-bp mouse pro alpha 1(I) collagen promoter, which is silent in transgenic mice. Hence, our data suggest that a far-upstream enhancer element plays a role in regulating high levels of expression of the mouse pro alpha 2(I) collagen gene.

How many general surgeons do you need in rural areas? Three approaches to physician resource planning in southern Manitoba

OBJECTIVE

To assess critically the results of using three different approaches to planning for the number of general surgeons in rural areas.

DESIGN

Estimates of the number of general surgeons needed using a ratio approach, a and a population-needs-based approach.

SETTING

Rural southern Manitoba.

OUTCOME MEASURE

Number of general surgeons needed.

RESULTS

The ratio approach supported the recruitment of 7.8 to 14.5 additional general surgeons to rural southern Manitoba. The repatriation approach suggested that the area might support five additional general surgeons, if residents could be persuaded to undergo their surgery closer to home. The population-needs-based approach suggested that the health status of area residents was similar to that of residents of other areas of the province and that they had a higher rate of surgery than residents of other areas; no additional surgeons were apparently needed.

CONCLUSIONS

Each method has certain advantages, and none is necessarily useful in isolation. Hence, the most effective approach to planning for general surgeons is likely a combination of all three methods. Other factors that may be important include the type of payment structure and the need for professional groups to monitor variations in rates of surgery.

Experimental evaluation of a modular approach to mobilizing antitobacco influences of peers and parents

The experimental evaluation of two components of a community intervention to prevent adolescent tobacco use are described. Youth antitobacco activities (e.g., peer quizzes, sidewalk art, poster and T-shirt giveaways, etc.) and family communications activities (pamphlets to parents and student quizzes of parents) were evaluated in two time-series experiments, each of which was conducted in two experimental and one control community. Students in Grades 6 and 8 and their parents were assessed in a series of four phone surveys in the first experiment and six phone surveys in the second. Implementation of the youth antitobacco and family communications activities led to significantly greater exposure of young people to antitobacco information. They led to increases in parent and youth knowledge about tobacco use and more negative attitudes toward tobacco. In Experiment 2, youths in intervention communities had significantly lower rated intentions to smoke. The findings suggest the value of a modular approach to community interventions for influencing the social context relevant to the onset of adolescent tobacco use.

Scleroderma-derived human fibroblasts retain abnormal phenotypic and functional characteristics following retroviral transduction with the SV40 tsT antigen

In this study an amphotropic retrovirus has been used to efficiently transduce normal human (NF) and scleroderma (systemic sclerosis; SSc) dermal fibroblasts (SScF) with a sequence encoding a temperature-sensitive mutant of the SV40 large T antigen (tsA58-U19). From the primary outgrowths of skin explants, cultures were generated whose growth was stringently temperature-dependent. When grown at a low, permissive temperature (35 degrees C), both normal and SSc-transduced cells continuously divided with similar doubling times, whereas at a high, nonpermissive temperature (39.5 degrees C), division of both the NF and SScF cells was rapidly arrested. These cells have been passaged more than 50 times, have the typical morphological appearance of fibroblasts, and have retained an anchorage-dependent phenotype. The transduced normal cells (tsT-NF) synthesized the matrix molecules collagen and fibronectin and expressed phenotypic antigens characteristic of their nontransduced counterparts, including MHC Class I, VLA beta 1 (CD29), Hermes 1 (CD44), VLA-4 alpha (CD49d), ICAM-1 (CD54) and LFA-3 (CD58) and the cell surface ectoenzymes neutral endopeptidase (CD10), aminopeptidase N (CD13), and dipeptidyl peptidase IV (CD26). Analysis of the transduced SSc fibroblasts (tsT-SScF) showed that these cells exhibited certain major features of the SSc pathology, notably the abnormally high synthesis of type I collagen, increased expression of ICAM-1, and depressed levels of CD26. Moreover, these phenotypic characteristics were retained even after prolonged culture in vitro. The tsT-SScF cells also retained their responsiveness to cytokines, since interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF-alpha) both produced a marked increase in ICAM-1 expression. Our findings show that infection of SScF with the SV40 tsT antigen extends the life span of these cells and does not ablate their abnormal phenotypic and functional characteristics.

Malabsorption caused by coeliac disease in patients who have scleroderma

Coeliac disease may account for malabsorption in scleroderma patients even when test suggest bacterial overgrowth. A small bowel biopsy is essential.

Community perceptions of adolescent health and sexuality. Results from a southern community-based project

OBJECTIVE

To describe the attitudes about adolescent health issues, especially school-based health services, held by adults in a rural community.

DESIGN

"Before-after," quasi-experimental design involving independent, cross-sectional population-based surveys in 1989 and 1992.

SETTING

Rural county located in the southeastern United States.

PARTICIPANTS

Probability sample of adults, 18 years and older, who were residents of the county, including 831 respondents in the first survey and 210 respondents in the second survey.

INTERVENTION

County-wide public education campaign involving public service announcements on television and radio, newspaper advertisements, posters, and open-to-the-public adolescent health programs and events.

MAIN OUTCOME MEASURES

Attitudes about the types of health services that should be included in a public school-based adolescent health program.

RESULTS

Rural adults' attitudes toward public school-based adolescent health services were similar before and after the community-wide campaign. Respondents believed the public schools should provide teenagers with information and counseling on substance abuse, sexual activity, birth control, and the acquired immunodeficiency syndrome but should not provide primary health care or birth control products. Most adults believed that sex and acquired immunodeficiency syndrome education should begin before high school.

CONCLUSIONS

A comprehensive, public school-based adolescent health program providing health information but not health services may be acceptable to this community. Adults' attitudes about adolescent health issues do not appear to have been modified by the adolescent health awareness campaign.

ABC of rheumatology. Raynaud's phenomenon, scleroderma, and overlap syndromes

Images

Expression of ectopeptidases in scleroderma

OBJECTIVES

To examine the expression and concentrations of three ectopeptidases likely to be involved in regulating the functional levels of adhesion molecules and the turnover of connective tissue components, in patients with scleroderma (systemic sclerosis) (SSc) and in normal individuals.

METHODS

Monoclonal antibodies against these antigens were used for immunoperoxidase staining of cryostat skin sections and for flow cytometric (fluorescence activated cell sorter) analysis of cultured dermal fibroblasts grown from SSc patients and normal controls.

RESULTS

Although neutral endopeptidase-24.11 (NEP) (CD10) was not detected in either SSc or normal skin, aminopeptidase N (APN) (CD13) and dipeptidyl peptidase IV (DPPIV) (CD26) were both readily visualised. However, DPPIV appeared to be present in smaller concentrations in the SSc biopsy specimens. Moreover, while fibroblasts grown in vitro from both SSc and normal skin also had similar concentrations of APN, the expression of DPPIV in the cultured SSc cells was found to be very much less than that present in the normal fibroblasts. It is noteworthy that NEP, which was not detected in the tissue sections, was nevertheless readily detected in fibroblasts in culture.

CONCLUSIONS

These results show that a number of cell surface proteases are expressed by dermal fibroblasts both in vivo and in vitro, and it is suggested that the marked downregulation of DPPIV in SSc could be at least partly responsible for the increased concentrations of adhesion molecules and matrix proteins associated with the molecular pathology of this disease.

Antiasthmatic effects of a leukotriene biosynthesis inhibitor (MK-0591) in allergic dogs

Peptidoleukotrienes may be important mediators of human bronchial asthma. Accordingly, the effects of a selective leukotriene (LT) biosynthesis inhibitor (MK-0591) were assessed in allergic dogs characterized by acute bronchoconstriction and subsequent airway hyperresponsiveness induced by inhaled ragweed allergen. Peak acute increases in airway resistance (Rrs) induced by ragweed were associated with increased bronchoalveolar lavage histamine concentration, and neither parameter was inhibited by MK-0591 (8 micrograms.kg-1.min-1 i.v.). However, the duration of the bronchoconstriction was significantly decreased by MK-0591, with a reduction in the area under the curve of 40% (P < 0.05). Associated with the acute bronchoconstriction in placebo-treated animals was a fivefold increase in urinary LTE4 excretion (as seen with allergic asthmatic patients), which was reduced to < 10% of basal values by MK-0591. Similarly, whole blood LTB4 biosynthesis was abolished in the MK-0591-treated animals. Bronchial hyperresponsiveness preallergen (measured as the percent concentration of acetylecholine required to increase Rrs by 5 cmH2O.l-1.s) tended to improve with MK-0591 (0.41 +/- 0.15 vs. 0.23 +/- 0.05%). Five hours after allergen inhalation, the percent concentration declined substantially in the placebo group (0.07 +/- 0.02%; P < 0.01), revealing an increased airway responsiveness that was significantly blunted by MK-0591 (0.26 +/- 0.07%; P < 0.001). These data suggest that selective inhibition of LT biosynthesis by novel compounds such as MK-0591 may modify the airway changes associated with bronchial hyperresponsiveness, as well as offer symptomatic relief in asthma.

Manitoba's population-based databases and long-term planning: beyond the hospital databases

The Manitoba Centre for Health Policy and Evaluation (MCHPE) conducts health services research focusing on Manitoba's administrative databases. Administrative databases contain information which is routinely and systematically collected for administrative purposes such as hospital and physician claims and funding requirements. This article describes the MCHPE's five major databases, their strengths and limitations, and the development of the Population Health Information System (PHIS). Four modules from PHIS illustrate how the data are used to provide useful information for health care planners, administrators and policy analysts. Finally, future projects and directions for using administrative databases are explored.

Collagen type I is not under autocrine control by transforming growth factor-beta 1 in normal and scleroderma fibroblasts

BACKGROUND

The ability of transforming growth factor-beta (TGF-beta) to induce synthesis of extracellular matrix proteins stimulated this study in which we address the hypothesis that TGF-beta can induce, in normal fibroblasts, the sustained, elevated collagen synthesis characteristic of the scleroderma fibroblast.

EXPERIMENTAL DESIGN

Fibroblasts were studied for synthesis of and responsiveness to TGF-beta. Secreted TGF-beta levels were determined in a bioassay and at the transcriptional level in a series of scleroderma (SSc) and normal fibroblasts. The ability of cells to interact functionally with a 3-dimensional collagen matrix after TGF-beta treatment was examined. The kinetics of TGF-beta-induced fibrosis in fibroblasts was studied.

RESULTS

SSc fibroblasts were not characterized by elevated TGF-beta synthesis. There was no evidence of coordinate regulation of TGF-beta and collagen over passage number. Repeated pulses of 200 pM of TGF-beta did not significantly induce sustained procollagen alpha 1(I) mRNA synthesis in normal fibroblasts, and this treatment did not significantly alter the characteristics of normal fibroblasts in a collagen gel. mRNA for both collagen and TGF-beta type II receptor was induced by TGF-beta in both SSc and control cells. SSc fibroblasts were found to have an impaired ability to activate the small latent complex of TGF-beta.

CONCLUSIONS

Our data give no support to the hypothesis that TGF-beta can maintain the SSc phenotype in vitro or that it is able to induce this phenotype. The inducibility of TGF-beta receptor mRNA in SSc fibroblasts after exposure to TGF-beta suggests that the lack of sustained elevation in collagen synthesis is not due to lack of responsiveness by the fibroblasts but is rather a reflection of the transient nature of TGF-beta-induced fibrosis.

Excess matrix accumulation in scleroderma is caused partly by differential regulation of stromelysin and TIMP-1 synthesis

Scleroderma (systemic sclerosis: SSc) is an autoimmune disorder in which excessive extracellular matrix is deposited in skin and internal organs. Because of the importance of metalloproteinases in the turnover of connective tissue, in this study we have developed a novel procedure which utilises flow cytometry (FACS) to measure the production of stromelysin (MMP-3), gelatinase A (MMP-2), and the proteinase inhibitor TIMP-1, by SSc skin fibroblasts. In the presence of monensin, which prevents the secretion of these matrix proteins, there was a similar intracellular accumulation of gelatinase A in normal and SSc cells. However, whereas stromelysin levels also increased in the normal cells, no net synthesis could be detected in the SSc fibroblasts. In marked contrast, the synthesis of TIMP-1 was 50% greater in the SSc cells than in the normal fibroblasts. Our results thus show unequivocally, for the first time, that cells from SSc patients simultaneously produce less stromelysin but substantially higher amounts of TIMP-1 than do normal dermal fibroblasts, suggesting that abnormalities in the regulation of the matrix enzymes and their inhibitors play an important part in the molecular pathology of SSc.

Expression and shedding of intercellular adhesion molecule 1 and lymphocyte function-associated antigen 3 by normal and scleroderma fibroblasts. Effects of interferon-gamma, tumor necrosis factor alpha, and estrogen

OBJECTIVE

To examine intercellular adhesion molecule 1 (ICAM-1) and lymphocyte function-associated antigen 3 (LFA-3) in cultures of normal and systemic sclerosis (SSc) dermal fibroblasts.

METHODS

The surface and soluble forms of ICAM-1 and LFA-3 were measured by flow cytometry and capture enzyme-linked immunosorbent assay, respectively.

RESULTS

Surface ICAM-1 was significantly higher on SSc fibroblasts compared with normal controls. Beta-estradiol did not directly enhance ICAM-1 or LFA-3 expression in either normal or SSc cells, but significantly augmented the cytokine-induced increase in ICAM-1. Soluble ICAM-1 (sICAM-1) and sLFA-3 were detected in fibroblast cultures. While no difference was found in the level of sLFA-3, the shedding of sICAM-1 was significantly increased (P < 0.001) in cells from SSc patients.

CONCLUSION

SSc fibroblasts express intrinsically elevated levels of surface ICAM-1 and release higher levels of sICAM-1 in vitro. Increased expression of ICAM-1 by interferon-gamma and tumor necrosis factor alpha alone, and the further induction in combination with beta-estradiol may underlie an aspect of fibroblast dysfunction in SSc and the female predisposition to the disease.

HLA-DQB1 associations with anti-topoisomerase-1 antibodies in patients with systemic sclerosis and their first degree relatives. United Kingdom Systemic Sclerosis Study Group

The frequency and functional properties of anti-topoisomerase-1 antibodies (ATA) have been studied in 58 systemic sclerosis (SSc) probands, 218 first degree relatives and 22 spouses. The dependence of ATA on the presence of certain HLA-DRB1 and HLA-DQB1 alleles was examined. ATA were detected by immunodiffusion, by absorption or inhibition of topoisomerase-1 enzymic activity, by immunoblotting of a K562 cell extract and by immunoprecipitation of 35S radiolabelled cell lines. HLA class II typing for HLA-DRB1 and HLA-DQB1 was performed by oligonucleotide typing in 49 families. Six probands and two relatives had ATA. The relatives with ATA had SSc. All eight individuals with ATA directly inhibited topoisomerase-1 function. Four of the eight had limited skin disease and four had diffuse skin involvement. The seven who were genotyped had at least one HLA-DQB1 allele encoding for tyrosine at position 30 of the first domain. Therefore, ATA are not widely dispersed within families, but rather are only present in those with SSc, and certain genetic requirements appear necessary for their generation.

Localization of endothelin-1 and its binding sites in scleroderma skin

OBJECTIVE

Endothelin-1 (ET-1) has been implicated in the pathogenesis of systemic sclerosis (SSc) as it is both a potent vasoconstrictor and fibroblast mitogen and is raised in the circulation of patients with SSc and primary Raynaud's phenomenon.

METHODS

We examined the localization and level of expression of ET-1 and its putative receptors in clinically "uninvolved" (i.e., prescleroderma skin) and involved skin from patients with diffuse cutaneous systemic sclerosis (dcSSc), using the alkaline phosphatase antialkaline phosphatase technique while ET-1 binding sites were examined using in vitro autoradiography.

RESULTS

There was an increase in dermal ET-1 staining in clinically uninvolved and involved skin from patients with early active dcSSc compared with late stage fibrotic SSc skin and normal skin from healthy volunteers. Increased ET-1 staining was associated predominantly with the superficial vessels in the SSc skin sections. In addition, there was a significant increase in [125I]ET-1 binding to superficial vessels and the dermal/epidermal junction in SSc skin compared with the binding to similar structures in normal tissue. There was no change in [125I]ET-1 binding to the deep dermal vessels in both SSc and normal skin. This increase in [125I]ET-1 binding in SSc skin was not maintained with increasing tissue fibrosis.

CONCLUSION

The presence of increased ET-1 levels as well as its binding sites in both the prescleroderma and involved skin of patients with dcSSc compared to controls suggests that ET-1 may play a role in the pathology of dermal fibrosis and vasoconstriction in SSc.

Increased urinary LTE4 excretion following inhalation of LTC4 and LTE4 in asthmatic subjects

Urinary leukotriene E4 (LTE4) increases during exacerbations of asthma and following antigen challenge. We determined whether urinary LTE4 excretion reflects sulphidopeptide leukotrienes in the airways of asthmatic patients. Urinary LTE4 concentration was measured prior to and 1.5 and 3.5 h following inhalation of bronchoconstrictive doses of leukotriene C4 (LTC4) or LTE4 in eight asthmatic subjects. Increasing doses of agonist were inhaled until a 35% fall in specific airways conductance (sGaw) was achieved. There was no significant difference between the 53 +/- 3% (mean +/- SEM) fall in sGaw following inhalation of LTC4 (63.1 ng geometric mean, GM, range 5.8-527.5 ng) and the 43 +/- 4% fall in sGaw following inhalation of LTE4 7.94 ng/GM (range 132-3701 ng). The LTE4 excretion rate increased significantly from 2.95 (range 0.6-17.5) ng.h-1 to 4.67 (range 0.8-20) ng.h-1 at 1.5 h following LTC4 inhalation; and from 1.8 (range 0.07-6.7) ng.h-1 to 6.9 (range 2.9-27.3) ng.h-1 at 1.5 h following LTE4 inhalation; and had returned from baseline by 3.5 h. There was a correlation between the dose of LTC4 inhaled and LTE4 excreted in the urine (r = 0.82 and r = 0.72, respectively). The % recovery of LTE4 in the urine, of the total dose of inhaled LTC4 or LTE4 administered, was 6.9 +/- 4.1% and 0.8 +/- 0.3%, respectively. Thus, inhalation of bronchoconstricting doses of LTC4 or LTE4 alter urinary LTE4 excretion in a dose-dependent fashion. This indicates that urinary LTE4 can be used as a marker of sulphidopeptide leukotriene synthesis in the lungs of patients with asthma.

Fibroblastic rheumatism

The first British case of fibroblastic rheumatism is reported. Treatment with apha-interferon in combination with a reducing course of steroids resulted in some regression of the cutaneous nodules, and initial improvement in the skin fibrosis and digital contractures.