Development of a novel flow cytometric cell-mediated cytotoxicity assay using the fluorophores PKH-26 and TO-PRO-3 iodide

A flow cytometric (FCM) assay has been developed for the determination of cell-mediated cytotoxicity (CMC). In the assay, the target tumour cell population was labelled with a membrane dye, PKH-26, prior to incubation with splenocyte effector cells. Cell death within the target population was assessed by the addition of the viability probe TO-PRO-3 iodide (TP3) and analysed by flow cytometry. The extent of cytotoxicity was determined by the relative number of live target cells labelled with PKH-26 only and dead, permeabilised cells labelled with both PKH-26 and TP3. This CMC method allows the analysis to be conducted on a single cell basis and overcomes the need for radiochemicals. This communication indicates that the FCM assay is an accurate and reproducible experimental system capable of analysing natural killer (NK) cell and antibody-dependent cell-mediated cytotoxicity. The procedure is comparable to the chromium release assay. We believe that this is one of the first demonstrations of an FCM-based antibody-dependent cell-mediated cytotoxicity (ADCC) assay.

Assessing pain in people with profound learning disabilities

People with profound learning and multiple disabilities are at risk of pain because they experience complex and severe health conditions and frequently undergo surgical procedures that cause pain. Pain assessment in this client group requires a skilled approach, although there is little evidence available to guide nursing practice. In the absence of pain assessment measures specifically designed for use with people with profound learning disabilities, the nurse will need to rely on careful observation and interpretation of the client's communicative behaviour, clinical judgement and knowledge of the person during assessment. Intuition is also an important attribute and can be a valuable source of knowledge when assessing clients who are unable to verbalize their experience of pain. These issues, along with implications for nursing practice, are explored.

The community integration measure: development and preliminary validation

OBJECTIVE

To present a new measure of community integration, the Community Integration Measure (CIM), and to offer preliminary information about its psychometric properties.

DESIGN

Validation study.

SETTING

Community.

PARTICIPANTS

Ninety-two participants placed in 3 subgroups (brain injury survivors, n = 41; significant others, n = 36; college students, n = 15).

MAIN OUTCOME MEASURES

The distributional properties, factor structure, internal consistency reliability, content validity, discriminant validity, concurrent validity, and construct validity of the CIM.

RESULTS

All items correlated positively with each other and with the total score. Principal components factor analysis confirmed a 1-factor structure, which explained 44.1% of the variance. Internal consistency reliability, using Cronbach's alpha, was.87. Content validity was assured by the development procedure, correspondence with the theoretical model, and direct use of consumer language. Discriminant validity was supported by the CIM's ability to differentiate between subsamples. Criterion validity was supported by using correlations with the Community Integration Questionnaire. Construct validity was supported by correlations with the Interpersonal Support Evaluation List.

CONCLUSION

The CIM offers a brief, easily administered measure of community integration that conforms to an empirically derived theoretical model and is psychometrically sound.

Phase I study of a decision aid for patients with locally advanced non-small-cell lung cancer

PURPOSE

Many patients with locally advanced non-small-cell lung cancer (LA-NSCLC) are eligible for combined-modality therapy (CMT; chemotherapy and radiotherapy). Although CMT offers slightly higher chances of survival than radiotherapy alone (RT), it also carries a higher probability of toxicity, raising the possibility that some patients may prefer to decline CMT. We report a pilot study of a decision aid designed for patients in this setting.

PATIENTS AND METHODS

The aid included a structured description of the treatment options and trade-off exercises designed to help clarify the patient's values for the relevant outcomes by determining the patient's survival advantage threshold (SAT; the increase in survival conferred by CMT over RT that the patient deemed necessary for choosing CMT). Additional outcome measures included each patient's strength of treatment preference, decisional conflict, objective understanding of survival information, and decisional role preference.

RESULTS

Twenty-seven patients met the eligibility criteria for the study. Of these, seven declined the decision aid because they had a clear treatment preference. The remaining 20 participants completed the decision aid; 18 chose CMT, and two chose RT. All 20 patients wished to participate in the decision to some extent. All patients reported that using the decision support was useful to them and recommended its use for others. No patient or physician reported that the aid interfered with the physician-patient relationship. Patients' 3-year SATs and median SATs were each strongly correlated with their strengths of treatment preference (rho = 0.83, P <.001 and rho = 0.67, P =.02, respectively). For all but one patient, either their 3-year or median survival threshold was consistent with their final treatment choice. Ten patients reported a stronger treatment preference after using the decision aid.

CONCLUSION

We conclude that implementing the decision-aid for patients with LA-NSCLC is feasible, that it demonstrates convergent validity, and that it is favorably evaluated by patients and their physicians. The aid seems to help patients understand the benefits and risks of treatment and to choose the treatment that is most consistent with their values. Further evaluation of the aid is warranted.

Methods to improve diagnostic accuracy in a community mental health setting

OBJECTIVE

This study determined the extent to which adding structured procedures improved diagnostic accuracy for outpatients with severe mental illness in a community mental health setting.

METHOD

The Structured Clinical Interview for DSM-III-R (SCID) was used to interview 200 psychiatric outpatients. A research nurse reviewed medical records and amended the SCID diagnoses accordingly. A research psychiatrist or psychologist reviewed the diagnostic data and interviewed each patient to verify or further modify the previous findings. Diagnostic outcomes at each step of the procedure were compared to determine whether adding additional data improved diagnostic accuracy. The additional time required for each element of the diagnostic procedure was also assessed.

RESULTS

Kappa comparisons of the different diagnostic levels showed that adding additional data significantly improved accuracy. Diagnoses rendered by combining the SCID and review of the medical record were the most accurate, followed by the SCID alone, and then diagnoses made by psychiatrists during routine care. In addition, the SCID alone identified five times as many current and past secondary diagnoses as were documented routinely in patients' charts.

CONCLUSIONS

Combining structured interviewing with a review of the medical record appears to produce more accurate primary diagnoses and to identify more secondary diagnoses than routine clinical methods. The patients' knowledge of their diagnoses was limited, suggesting a need for patient education in this setting. Whether use of structured interviewing in routine practice improves patient outcomes deserves further study.

Pesticide residues in the Canadian Market Basket Survey--1992 to 1996

Market basket food samples from six Canadian cities collected from 1992 to 1996 were analysed for pesticide residues. One hundred and thirty-six composites were prepared for each city, representing 99% of the Canadian diet. Residues were found most frequently in peanut butter and butter. DDE, malathion and captan occurred most frequently, while the fungicides chlorothalonil, dicloran and captan were present in the highest concentrations. Processed commodities contained fewer residues and at lower concentrations than the raw products. No residues were detected in either milk or soy-based infant formula. Of the infant foods sampled, fruit contained both the greatest number and highest concentrations of pesticides.

The accuracy of oral predictive and infrared emission detection tympanic thermometers in an emergency department setting

OBJECTIVE

To assess the accuracy of an oral predictive thermometer and an infrared emission detection (IRED) tympanic thermometer in detecting fever in an adult emergency department (ED) population, using an oral glass mercury thermometer as the criterion standard.

METHODS

This was a single-center, nonrandomized trial performed in the ED of a metropolitan tertiary referral hospital with a convenience sample of 500 subjects. The temperature of each subject was taken by an oral predictive thermometer, an IRED tympanic thermometer set to "oral" equivalent, and an oral glass mercury thermometer (used as the criterion standard). A fever was defined as a temperature of 37.8 degrees C or higher. The subject's age, sex, triage category, and diagnostic group were also recorded. Sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values, and corresponding 95% confidence intervals were calculated. Logistic regression was used to identify predictors of fever.

RESULTS

The sensitivities and specificities for detection of fever of the predictive and the IRED tympanic thermometers were similar (sensitivity 85.7%/88.1% and specificity 98.7%/95.8%, respectively). The predictive thermometer had a better positive predictive value (85.7%) compared with the IRED tympanic thermometer (66.1%). The positive and negative likelihood ratios for the predictive oral thermometer were 65 and 0.14, respectively, and for the IRED tympanic thermometer 21 and 0.12, respectively, indicating that the predictive thermometer will "miss" 1 in about 7 fevers and the IRED tympanic thermometer will "miss" 1 in about 8 fevers.

CONCLUSIONS

Although quick and convenient, oral predictive and IRED tympanic thermometers give readings that cannot always be relied on in the detection of fever. If we are to continue using electronic thermometers in the ED setting, we need to recognize their limitations and maintain the importance of our clinical judgment.

Normal and c-Myc-promoted human keratinocyte differentiation both occur via a novel cell cycle involving cellular growth and endoreplication

The relationship between cell cycle and differentiation in human keratinocytes is poorly understood. It is believed that keratinocytes suppress DNA replication and cell cycle arrest in G0 before they initiate terminal differentiation. However, a temporal separation between both events has not been established. Moreover, c-Myc promotes keratinocyte differentiation without causing cell cycle arrest. To address these paradoxes we have analysed cell cycle control during normal and c-Myc-promoted differentiation. Continuous activation of c-Myc or initiation of terminal differentiation results in a block of G2/M, cellular growth, endoreplication and polyploidy. Keratinocytes abandon G1, continue replicating DNA as they differentiate terminally and become polyploid. In fact, simply blocking mitosis with nocodazole resulted in increased cell size, terminal differentiation and endoreplication. This indicates that terminal differentiation associates with defective cell cycle progression and provides a novel insight into c-Myc biology.

Microtubules, but not actin microfilaments, regulate vacuole motility and morphology in hyphae of Pisolithus tinctorius

While it is now recognised that transport within the endomembrane system may occur via membranous tubules, spatial regulation of this process is poorly understood. We have investigated the role of the cytoskeleton in regulating the motility and morphology of the motile vacuole system in hyphae of the fungus Pisolithus tinctorius by studying (1) the effects of anti-microtubule (oryzalin, nocodazole) and anti-actin drugs (cytochalasins, latrunculin) on vacuolar activity, monitored by fluorescence microscopy of living cells; and (2) the ultrastructural relationship of microtubules, actin microfilaments, and vacuoles in hyphae prepared by rapid-freezing and freeze-substitution. Anti-microtubule drugs reduced the tubular component of the vacuole system in a dose-dependent and reversible manner, the extent of which correlated strongly with the degree of disruption of the microtubule network (monitored by immunofluorescence microscopy). The highest doses of anti-microtubule drugs completely eliminated tubular vacuoles, and only spherical vacuoles were observed. In contrast, anti-actin drugs did not reduce the frequency of tubular vacuoles or the motility of these vacuoles, even though immunofluorescence microscopy confirmed perturbation of microfilament organisation. Electron microscopy showed that vacuoles were always accompanied by microtubules. Bundles of microtubules were found running in parallel along the length of tubular vacuoles and individual microtubules were often within one microtubule diameter of a vacuole membrane. Our results strongly support a role for microtubules, but not actin microfilaments, in the spatial regulation of vacuole motility and morphology in fungal hyphae.

Birth size and arterial compliance in young adults

Impaired fetal growth may cause reduced compliance of the aorta and other large arteries, and predispose an individual to higher blood pressure in later life. We found that neither low birth size nor interaction between birth size and adult size were associated with arterial pulse-wave velocity in men and women aged 25 years.

Making a difference to practice: clinical benchmarking. Part 2

In the second of two articles, the authors explore further the use of clinical practice benchmarking. In particular, practice related to improving nutritional care for patients, caring for patients with mental health needs and safely transferring critically ill patients is examined. The authors conclude by summarising the value of clinical practice benchmarking and how it made a difference to practice in their trust. The first article appeared in Nursing Standard last week.

Ulceration of the urethral meatus after simultaneous pancreas-kidney transplantation

A 39-year-old male developed painful ulceration of the glans penis following simultaneous pancreas and kidney transplantation for end-stage renal failure complicating insulin-dependent diabetes mellitus. Infection was excluded. Diversion of the pancreatic secretions away from the urinary bladder into the bowel resulted in healing.

Making a difference to practice: clinical benchmarking. Part 1

In the first of two articles, the authors describe how an internal clinical practice benchmarking group was established in Preston to compare and share examples of best practice. The aim was to ensure consistent high standards of care practice across the trust. Activity related to discharge planning and visiting is used here to illustrate the effectiveness of clinical practice benchmarking as a continuous quality improvement tool. The second article will appear in Nursing Standard on May 3.

ER-Tracker dye and BODIPY-brefeldin A differentiate the endoplasmic reticulum and golgi bodies from the tubular-vacuole system in living hyphae of Pisolithus tinctorius

Two fluorochromes, ER-TrackerTM Blue-White DPX dye and the fluorescent brefeldin A (BFA) derivative, BODIPY-BFA, label the endoplasmic reticulum (ER) in hyphal tips of Pisolithus tinctorius and allow its differentiation from the tubular-vacuole system at the light microscope level in living cells. The ER-Tracker dye labels a reticulate network similar in distribution to ER as seen in electron micrographs of freeze-substituted hyphae. BODIPY-BFA stains a thicker axially aligned structure with an expanded region at the apex, which is similar to that seen when hyphae are stained with ER-Tracker dye in the presence of unconjugated BFA. This structure is considered to be ER modified by BFA, a view supported by ultrastructural observations of the effect of BFA on the fungal ER. Both fluorescent probes also stain punctate structures, which are most likely to be Golgi bodies. Neither probe labels the tubular-vacuole system.

Brefeldin A affects growth, endoplasmic reticulum, Golgi bodies, tubular vacuole system, and secretory pathway in Pisolithus tinctorius

Brefeldin A (BFA) reduced radial growth in Pisolithus tinctorius at a concentration as low as 2 microM. Use of endoplasmic reticulum (ER)-Tracker dye, unconjugated BFA, and fluorescent BFA (BODIPY-BFA) allowed comparison of the effects of BFA on the endomembrane system of P. tinctorius at the light and electron microscope levels. Both ER-Tracker dye and BODIPY-BFA have been shown previously to label the ER. Unconjugated BFA and BODIPY-BFA modified the ER network and disrupted the tubular vacuole system in the tip region. The ultrastructure in freeze-substituted hyphae showed that BFA treatment resulted in (i) disruption of the Spitzenkörper, (ii) reduction in number of apical vesicles, (iii) redistribution and mild dilation of ER, and (iv) persistence and increased size and complexity of Golgi bodies. The effects of BFA on the ER were only partially reversible in the time period examined. We conclude that in P. tinctorius, BFA as the free metabolite or BODIPY-BFA affects the tubular vacuole system as well as anterograde membrane flow between the ER and the Golgi bodies and post-Golgi transport.

Antineutrophil cytoplasmic antibodies and associated diseases: a review of the clinical and laboratory features

There have been a number of recent advances in this field. First, the "International Consensus Statement on Testing and Reporting of Antineutrophil Cytoplasmic Antibodies (ANCA)" has been developed to optimize ANCA testing. It requires that all sera are tested by indirect immunofluorescent (IIF) examination of normal peripheral blood neutrophils and, where there is positive fluorescence, in enzyme-linked immunosorbent assays (ELISAs) for antibodies against both proteinase 3 (PR3) and myeloperoxidase (MPO). Testing will be further improved when international standards and common ELISA units are available. Second, new diagnostic criteria for the small vessel vasculitides that take into account ANCA-positivity and target antigen specificity as well as histologic features are currently being produced. Third, we understand that the complications associated with treatment of the ANCA-associated vasculitides are often more hazardous than the underlying disease, and regimens that use effective but less toxic agents are being evaluated. The factors associated with increased risk of relapse, however, remain incompletely understood. Finally, ANCA with specificities other than PR3 and MPO are present in many nonvasculitic autoimmune diseases. Their clinical significance is still largely unclear, and some of the target antigens are present in other cells as well as neutrophils and thus are not strictly "ANCA."

Morphology of lymphatic malformations: a pictorial review

A pictorial review of the many clinical manifestations of lymphatic malformations is presented, changes to the terminology of lymphatic malformations are reviewed and the 'pros and cons' of relevant investigative techniques are discussed.

Validity and community utility of the Canadian Occupational Performance Measure

This study addressed the validity and community utility of the Canadian Occupational Performance Measure (COPM) (Law et al., 1991; 1994; 1998): a measure that now represents a national standard in clinical practice and research in occupational therapy in Canada. The study employed a crossectional design. Participants for the study were former consumers of occupational therapy services, recruited from the Queen's University catchment area (Kingston, North Bay, Oshawa, Perth, Peterborough). A sample of 61 disabled individuals living in the community were recruited. Each individual was sent a package of self-administered measures including the Satisfaction with Performance Scaled Questionnaire, the Reintegration to Normal Living Index, the Life Satisfaction Questionnaire, and the Perceived Problems List. An interview was also arranged with the project coordinator, which was based on the COPM and the Consumer Utility Questionnaire. Multivariate analyses showed that construct validity was supported; scores on the COPM were significantly related to theoretically related constructs: satisfaction with performance, reintegration to normal living and life satisfaction. In addition, criterion validity was supported. A majority of participants (53%), when asked about problems of daily living, spontaneously reported at least one of the problems raised on the COPM. Community utility was evaluated highly by participants, 75% of whom found the COPM useful in identifying and rating their problems, and 100% of whom reported no problems in understanding the COPM.

Localized microcystic lymphatic malformations--ultrasound diagnosis

Microcystic lymphatic malformations present with a wide variety of clinical manifestations that may make diagnosis difficult. We present four patients with microcystic lymphatic malformations that have been confirmed by both histology and ultrasound appearance. Five further cases of microcystic lymphatic malformations with unusual presentations, in which ultrasound was used to support the diagnoses, are then presented. The use of ultrasound as a tool to aid in the diagnosis of microcystic lymphatic malformations is then discussed and compared with other investigative techniques.

Combined antiviral treatment in HIV infection. Is it value for money?

There is compelling evidence that combinations of antiretroviral drugs are significantly more effective than monotherapy and appear, at least in the short run, to offset problems caused by the rapid emergence of drug resistance which is characteristic of human immunodeficiency virus (HIV) infection.1,2 The routine prescribing of combination antiretroviral therapy appears to have contributed to a fall in HIV-related in-patient admissions, mortality and morbidity, with a concomitant increase in pharmacy costs. In this paper we have attempted to determine to what extent the reduction in direct hospital costs (reduced in-patient admissions, diagnostic tests and management of complications) will offset the considerably increased pharmacy costs; by using Markhov modelling procedures together with locally gathered costs data.