Telephone or face-to-face interviews?: a decision made on the basis of a pilot study

De Vaus (1991) highlights five main considerations that may be key factors in decisions about whether to use telephone or face-to-face interviews for survey work: response rates, ability to produce representative samples, effects on interview schedule design, quality of responses and implementation problems. De Vaus' discussion of these five issues is outlined at the start of this article. The five issues are then applied to the experiences of researchers conducting a study on continence care. Description and discussion of pilot interviews, which explored both interview modes, are followed by a similar examination of the main study which employed telephone interviews. Ideas in this discussion are supported and challenged by reference to other publications on the subject of telephone and face-to-face interviews. The success of the decision to use telephone interviews in the main study is evaluated and recommendations are made.

Composition and function of peripheral blood stem and progenitor cell harvests from patients with severe active rheumatoid arthritis

High-dose chemotherapy with autologous stem cell rescue has been proposed as an intensive therapy for severe rheumatoid arthritis (RA). In view of previous observations of abnormal haemopoiesis in RA patients, the composition and function of peripheral blood stem cell harvests (PBSCH) was investigated. Compared with PBSCH from healthy allogeneic donors mobilized with the same dose of G-CSF (filgrastim; 10 microg/kg/d, n = 14), RA PBSCH (n = 9) contained significantly fewer mononuclear cells (375 v 569 x 10(6)/kg, P = 0.03) and CD34+ cells (2.7 v 5.8 x 10(6)/kg, P = 0.003). However, there were increased proportions of CD14+ cells (P = 0.006) and CD14+ CD15+ cells (the phenotype of previously described 'abnormal' myeloid cells, P = 0.002) in the RA PBSCH which translated into 3.5- and 7-fold increases respectively on a per CD34+ cell basis. There were no differences in T-cell activation status as judged by proportions of CD4+ and CD8+ expressing CD45RA, CD45RO, HLA-DR and CD28 (RA PBSCH, n = 7, donor PBSCH, n = 5, P = 0.2-0.7). Phytohaemagglutinin responses determined fluorocytometrically with induction of CD69 expression were reduced in CD4+ and CD8+ cells following filgrastim administration in 3/3 RA patients tested. Compared with bone marrow as a potential source of CD34+ cells, PBSCH contained 11-fold more T cells (P < 0.0005), 8-fold more B cells (P < 0.0005) and 4-fold more monocytes (P = 0.02). In short-term methylcellulose culture there were no differences in colony counts (CFU-GM, CFU-GEMM, BFU-E) per CD34+ cell from PBSCH from RA patients (n = 11) and healthy donors (n = 10). Long-term culture initiator cells were cultured successfully from cryopreserved PBSCH from RA patients (n = 9). In conclusion, PBSCH from RA patients differed significantly in composition from normal individuals, but in vitro studies support normal stem and progenitor cell function. Changes in T-cell function occur during mobilization in RA patients. This work provides reassurance for the use of PBSCH as haematological rescue and baseline data for clinical trials of graft manipulation strategies in patients with RA.

Factors affecting practice nurse involvement in follow-up care of patients following myocardial infarction

BACKGROUND

Preventive care can reduce the morbidity and mortality of patients following myocardial infarction. Recent evidence has shown that such care is not being provided effectively. The involvement of practice nurses has been proposed as a means of improving the completeness of follow-up and the quality of preventive care.

OBJECTIVES

We aimed to determine the extent to which follow-up care for people discharged from hospital after a myocardial infarction is currently being undertaken by practice nurses and to assess the factors influencing the provision of such care and the nurses' attitudes towards this extended role.

METHOD

Postal questionnaires were sent to 183 practice nurses working in general practices in the Southampton and South-West Hampshire Health District; 121 nurses responded (66%), representing 58 out of 64 practices surveyed (91%).

RESULTS

The majority of responding practice nurses (55%, 95% CI 47-64%) had hospital experience of caring for patients with ischaemic heart disease, and most (83%, 95% CI 76-89%) believed that they played a key role in follow-up care of patients following myocardial infarction. In the absence of external support from a cardiac liaison nurse, few nurses (26%, 95% CI 16-41%) provide such care at present and only 21% work in practices with a register of myocardial infarction patients. Factors predicting the provision of follow-up care are having adequate time (odds ratio 4.59, 95% CI 1.66-12.7), the support of a cardiac liaison nurse (odds ratio 3.07, 95% CI 1.28-7.34) and GP colleagues (odds ratio 3.38, 95% CI 1.38-8.23), training in consultation skills (odds ratio 7.25, 95% CI 2.08-25.3), fundholding (odds ratio 3.11, 95% CI 1.26-7.69) and the confidence and knowledge of the practice nurse (odds ratios and 95% CIs respectively: 2.84, 1.18-6.83 and 2.80, 1.13-6.89).

CONCLUSION

Most practice nurses are enthusiastic and have some of the necessary experience to provide follow-up care for patients who have experienced a myocardial infarction. Yet few currently provide it. The most important organizational incentives for providing such care are further training and the support of GPs and the cardiac liaison nurse.

Primary pulmonary hypertension between inflammation and cancer

We believe that the monoclonal cell expansion in primary pulmonary hypertension is the result of autonomous growth of stem cell-like endothelial cells, whereas the polyclonal proliferation in secondary pulmonary hypertension occurs as a response of endothelial cells to exogenous stimuli (like viral infection or high shear stress). In this context, we propose that different transcriptional and translational events govern the growth and expansion of monoclonal when compared with polyclonal pulmonary endothelial cells. The availability of antibodies directed against specific tyrosine kinase proteins involved in vasculogenesis/angiogenesis now permits the identification and localization of the components of such a misguided angiogenesis cell proliferation program in the pulmonary hypertensive vascular lesions.

Induction of phosphodiesterases 3B, 4A4, 4D1, 4D2, and 4D3 in Jurkat T-cells and in human peripheral blood T-lymphocytes by 8-bromo-cAMP and Gs-coupled receptor agonists. Potential role in beta2-adrenoreceptor desensitization

In this study, a potential mechanism of beta2-adrenoreceptor desensitization has been explored that is based upon the enhanced degradation of cAMP by phosphodiesterase (PDE). Pretreatment of Jurkat T-cells with 8-bromo cAMP (8-Br-cAMP) or prostaglandin E2 increased PDE3 and PDE4 activity in an actinomycin D- and cycloheximide-sensitive manner. This effect was associated with increased expression of HSPDE3B, HSPDE4A4, HSPDE4D1, HSPDE4D2, and HSPDE4D3 mRNA transcripts. Western analysis reproducibly labeled a band of immunoreactivity in vehicle-treated cells that corresponded to HSPDE4A4 (125 kDa). Although the intensity of this band was unchanged in cells treated with 8-Br-cAMP, additional 68-72-kDa proteins (HSPDE4D2, HSPDE4D1) were labeled that were not detected after vehicle. Similar results were obtained with T-lymphocytes exposed to 8-Br-cAMP and fenoterol. However, in those experiments HSPDE4A4 and HSPDE4D1 appeared to be equally expressed in vehicle- and treated cells, whereas HSPDE4D2 (72 kDa) was detected only after 8-Br-cAMP. The up-regulation of PDE activity in Jurkat T-cells abolished the ability of isoproterenol to elevate cAMP, which was partially reversed by the non-selective PDE inhibitor, 3-isobutyl-1-methylxanthine, and by the PDE3 and PDE4 inhibitors, Org 9935 and rolipram, respectively. Collectively, these data suggest that chronic treatment of T-cells with cAMP-elevating agents compromises beta2-adrenoreceptor-mediated cAMP accumulation by increasing the expression of HSPDE3B and HSPDE4D gene products.

Evaluation of acute physiology and chronic health evaluation III predictions of hospital mortality in an independent database

OBJECTIVE

To assess the accuracy and validity of Acute Physiology and Chronic Health Evaluation (APACHE) III hospital mortality predictions in an independent sample of U.S. intensive care unit (ICU) admissions.

DESIGN

Nonrandomized, observational, cohort study.

SETTING

Two hundred eighty-five ICUs in 161 U.S. hospitals, including 65 members of the Council of Teaching Hospitals and 64 nonteaching hospitals.

PATIENTS

A consecutive sample of 37,668 ICU admissions during 1993 to 1996; including 25,448 admissions at hospitals with >400 beds and 1,074 admissions at hospitals with <200 beds.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used demographic, clinical, and physiologic information recorded during ICU day 1 and the APACHE III equation to predict the probability of hospital mortality for each patient. We compared observed and predicted mortality for all admissions and across patient subgroups and assessed predictive accuracy using tests of discrimination and calibration. Aggregate hospital death rate was 12.35% and predicted hospital death rate was 12.27% (p =.541). The model discriminated between survivors and nonsurvivors well (area under receiver operating curve = 0.89). A calibration curve showed that the observed number of hospital deaths was close to the number of deaths predicted by the model, but when tested across deciles of risk, goodness-of-fit (Hosmer-Lemeshow statistic, chi-square = 48.71, 8 degrees of freedom, p< .0001) was not perfect. Observed and predicted hospital mortality rates were not significantly (p < .01) different for 55 (84.6%) of APACHE III's 65 specific ICU admission diagnoses and for 11 (84.6%) of the 13 residual organ system-related categories. The most frequent diagnoses with significant (p < .01) differences between observed and predicted hospital mortality rates included acute myocardial infarction, drug overdose, nonoperative head trauma, and nonoperative multiple trauma.

CONCLUSIONS

APACHE III accurately predicted aggregate hospital mortality in an independent sample of U.S. ICU admissions. Further improvements in calibration can be achieved by more precise disease labeling, improved acquisition and weighting of neurologic abnormalities, adjustments that reflect changes in treatment outcomes over time, and a larger national database.

Delayed external compression reduction of an omphalocele (DECRO): an alternative method of treatment for moderate and large omphaloceles

BACKGROUND/PURPOSE

Standard treatment of large hepatoomphaloceles has been SILASTIC (Dow Corning, Midland, MI) silo placement followed by closure. This requires two operations, and complications from the silo may occur. The authors have looked for a safe and simpler alternate method of closure. Delayed external compression reduction of an omphalocele (DECRO), appears to have a low complication rate and a rapid time to closure.

METHODS

The authors reviewed retrospectively the records of six patients with hepato-omphaloceles treated with DECRO from August 1993 to July 1997. All defects were evaluated by the attending surgeon and could not be closed primarily. All data are expressed as mean +/- SEM.

RESULTS

The average gestational age was 36.5 +/- 0.67 weeks with mean weight of 2,780 +/- 256 g. Two patients had congenital cardiac disease. The mean size of the defects was 6.2 x 5.7 cm. All defects had the liver out of the abdomen. No patients required silo placement. The mean time to reduction and final closure was 5.6 +/- 0.49 days. The average postoperative time on the ventilator was 7.1 +/- 3.5 days. Mean time to full feeds was 18.8 +/- 3.4 days. One patient had superficial necrosis of the skin flap. Mean time to discharge was 30.5 +/- 5.5 days. All patients had DECRO completed without complications.

CONCLUSIONS

This procedure decreases the number of operations needed from two to one. No complications were seen from the procedure and the time of mechanical ventilation required was low. The abdominal compartment syndrome developed in none of the patients. DECRO is a safe and very effective alternative to SILASTIC silo placement in moderate and large omphaloceles that cannot be closed primarily.

The role of the general practitioner in the community care of people with HIV infection and AIDS: a comparative study of high- and low-prevalence areas in England

BACKGROUND

Policy for the care of people suffering from HIV and AIDS has changed over the past decade. Schemes for shared primary and secondary care have been met with varying success, and patients may be reluctant to become involved. No systematic evaluation comparing the views of primary care providers and users in areas of varying HIV prevalence has been published.

AIM

To examine the role of general practice in areas of England with low and high human immunodeficiency virus (HIV) prevalence and to compare barriers to general practice care in each area.

METHOD

We used focus groups, semistructured questionnaires and interviews in north London (high HIV prevalence) and Nottingham (low HIV prevalence).

RESULTS

Four focus groups took place in London. A total of 411 general practitioners (GPs) in London and 405 in Nottingham replied to postal questionnaires. Overall, 121 primary care staff in 40 London practices and 26 staff in five Nottingham practices were interviewed. In all, 54 people infected with HIV were interviewed in London and 20 in Nottingham. Providers and users regarded the 24-hour availability and the familiar environment of general practice as its key assets. Lack of expertise and time were its disadvantages. Providers were concerned about inadequate communication with specialist services. Although providers were concerned about confidentiality, whether they had liberal and sympathetic attitudes was more important in deciding whether people with HIV used the service. In the low-prevalence area, general practice involvement was the result of individual initiatives, and practices were not integrated into specialist care. In the high-prevalence area, HIV care was more usual in general practice, but there was also little integration with HIV services.

CONCLUSIONS

In high-prevalence districts, a strategy to make HIV care routine for all GPs may be appropriate. In low-prevalence areas, a network of selected, strategically located, relatively high-involvement practices may be more effective in meeting the primary care needs of people with HIV infection and acquired immunodeficiency syndrome (AIDS).

Outcome measurement in adult stuttering therapy: a self-rating profile

The speech and language therapy profession is committed to the use of outcome measurement to maximise both efficiency and efficacy. However, measuring change in adult stuttering therapy is particularly problematic. It is proposed that outcomes of therapy should include stuttering behaviours, reactions to stuttering and handicap resulting from stuttering. Current methods of measuring change are reviewed. The Wright & Ayre Stuttering Self-Rating Profile (WASSP) is described which includes clients' perceptions of stuttering behaviours, avoidance, feelings and disadvantage. Issues of reliability and validity are considered.

5-Lipoxygenase and 5-lipoxygenase activating protein (FLAP) immunoreactivity in lungs from patients with primary pulmonary hypertension

Inflammatory infiltrates and endothelial cell proliferation have been appreciated in plexiform and concentric lesions, which characterize the vascular remodeling in primary pulmonary hypertension (PPH). Leukotriene production by perivascular and alveolar macrophages relies on activation of 5-lipoxygenase (5-LO), with translocation of the enzyme to the nuclear membrane, and association with the 5-LO activating protein (FLAP). Using immunohistochemical staining, we localized and semi-quantitatively estimated the abundance of 5-LO and FLAP in lungs obtained from patients with PPH, patients with interstitial lung disease (ILD), and normal control subjects. Expression of 5-LO and FLAP was prominent in alveolar macrophages in both the normal and PPH lungs; however, alveolar macrophages were more frequently clustered in the vicinity of remodeled blood vessel in PPH. Medium- and small-size pulmonary arteries in PPH showed more abundant FLAP expression than in control and ILD lungs. 5-LO expression in small arteries in PPH was more intense than in control and ILD patients. Endothelial cells in plexiform and concentric lesions in PPH expressed both 5-LO and FLAP. In situ hybridization confirmed the presence of 5-LO transcripts in macrophages and endothelial cells of the remodeled vessels in PPH. We propose that the overexpression of 5-LO and FLAP represents evidence for the participation of inflammation in the process of PPH vasculopathy or, alternatively, that the overabundance of the enzymes involved in generation of inflammatory mediators may themselves be related to vascular cell proliferation and cell growth.

Characterization of pigs transgenic for human decay-accelerating factor

BACKGROUND

To prevent the central role played by complement activation in the hyperacute rejection of pig organs transplanted into primates, pigs transgenic for human decay-accelerating factor (HDAF) have recently been produced. The data presented here extend previous immunohistochemical findings by documenting the immunological characterization and the levels of expression of HDAF in these transgenic pigs.

METHODS

Animals from 30 independently derived lines were included in this study. HDAF expression was characterized by immunoprecipitation and epitope mapping. Quantitative analysis was performed by radiometric assays followed by Scatchard analysis and by double-determinant radioimmunoassay. Deposition of iC3b on porcine aortic endothelial cells was determined by radioimmunoassay. DNA slot-blot analysis and densitometric scanning were used to evaluate HDAF transgene copy number.

RESULTS

The integrity of HDAF expressed by these transgenic pigs could be demonstrated. HDAF was present in 72% of the organs analyzed, although considerable variation in expression occurred, both between animals and within the same pig. High levels of HDAF on porcine aortic endothelial cells resulted in iC3b deposition at levels as low as that detected on human endothelial cells. Twenty-six organs expressed levels of HDAF greater than those observed in the equivalent human tissue. HDAF expression did not correlate with the number of copies of the transgene incorporated into the porcine genome.

CONCLUSIONS

Transgenic pigs, which express levels of functional HDAF even greater than those observed in humans, have successfully been produced. Pigs transgenic for human complement inhibiting molecules could represent a source of organs for future clinical xenotransplantation.

Expression of glutamyl-tRNA reductase in Escherichia coli

The biosynthesis of the hemes, chlorophylls, corrins and other tetrapyrroles begins with the synthesis of 5-aminolevulinic acid (ALA). The pathway is highly conserved except for the synthesis of ALA which is derived from glycine and succinyl CoA (C4) in most eukaryotes and from glutamate (C5) in most bacteria and in green plants. In C5, glutamyl-tRNA synthetase (GTS) converts glutamate to glutamyl-tRNA (glu-tRNA), which is reduced by glutamyl-tRNA reductase (GTR) to glutamyl-1-semialdehyde (GSA), which is converted by aminotransferase (GSA-AT) to ALA. Since GTS is also involved in protein synthesis and GSA can be converted to ALA non-enzymatically, it is highly probable that control of ALA synthesis and thus of the whole pathway resides in the GTR step. In Escherichia coli, GTR is the gene product of hemA. BL21(DE3), a protease-deficient strain which contains the T7 RNA polymerase gene in front of a lac promoter, was transformed with a pET14b-based vector, pWC01, harboring hemA in front of a T7 promoter and ORF1 which is transcribed in the opposite direction. The transformed strain, WC1201, secreted ALA and porphyrins into the medium. Induction of expression of hemA by WC1201 was optimized for concentration of inducer (IPTG, 5 mM), temperature (37 degrees C), presence of betaine and sorbitol (no change) and time of induction (2h). GTR was observable as a 46 kDa band by Brilliant blue G staining of SDS-PAGE gels. Sonicates of the induction mixture exhibited strong ALA synthesis activity which was enhanced by tRNAglu. Most of the activity was in the supernatant of the sonicate indicating that GTR is a soluble enzyme. The induced strain had more GTS activity than the uninduced strain which had more GTS activity than its parent wild-type strain. Autoradiography on native gradient PAGE showed that GTR expressed in vivo by induction of WC1201 had a molecular weight of approx. 117 kDa. Gel filtration of the induced sonicate showed a peak of enzymatic activity at about 126 kDa. When pET14b- or pUC19-based plasmids harboring hemA and ORF1, or importantly, a pUC19-based plasmid harboring only hemA and not ORF1, were expressed in an in vitro transcription-translation system, native gradient PAGE showed a product with a molecular weight of approximately 175 kDA. This expression was higher in the presence of tRNAglu. When the 117 kDa and 175 kDa proteins were excised from their native gels respectively, and run on SDS PAGE, autoradiography showed bands at 46 kDa. We conclude that GTR is present in both high molecular weight species. Since overexpression of hemA from pET14b-based plasmids is associated with increased glutamyl-tRNA synthetase activity, the 175 kDa species may represent different complexes of GTR, GTS and glutamyl-tRNA as observed in Chlamydomonas and the 117-126 kDa species may be an dimer of GTR associated with glu-tRNA or a complex of GTR, GTS and glu-tRNA. These possibilities are being investigated.

Evidence for the sensitivity of the SF-36 health status measure to inequalities in health: results from the Oxford healthy lifestyles survey

OBJECTIVES

The short form 36 (SF-36) health questionnaire may not be appropriate for population surveys assessing health gain because of the low responsiveness (sensitivity to change) of domains on the measure. An hypothesised health gain of respondents in social class V to that of those in social class I indicated only marginal improvement in self reported health. Subgroup analysis, however, showed that the SF-36 would indicate dramatic changes if the health of social class V could be improved to that of social class I.

DESIGN

Postal survey using a questionnaire booklet containing the SF-36 and a number of other items concerned with lifestyles and illness. A letter outlining the purpose of the study was included.

SETTING

The sample was drawn from family health services authority (FHSA) computerised registers for Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire.

SAMPLE

The questionnaire was sent to 13,042 randomly selected subjects between the ages of 17-65. Altogether 9332 (72%) responded.

OUTCOME MEASURES

Scores for the eight dimensions of the SF-36.

STATISTICS

The sensitivity of the SF-36 was tested by hypothesising that the scores of those in the bottom quartile of the SF-36 scores in class V could be improved to the level of the scores from the bottom quartile of SF-36 scores in class I using the effect size statistic.

RESULTS

SF-36 scores for the population at the 25th, 50th, and 75th centiles were provided. Those who reported worse health on each dimension of the SF-36 (ie in the lowest 25% of scores) differ dramatically between social class I and V. Large effect sizes were gained on all but one dimension of the SF-36 when the health of those in the bottom quartile of the SF-36 scores in class V were hypothesised to have improved to the level of the scores from the bottom quartile of SF-36 scores in class I.

CONCLUSIONS

Analysis of SF-36 data at a population level is inappropriate; subgroup analysis is more appropriate. The data suggest that if it were possible to improve the functioning and wellbeing of those in worst health in class V to those reporting the worst health in class I the improvement would be dramatic. Furthermore, differences between the classes detected by the SF-36 are substantial and more dramatic than might previously have been imagined.

Portability issues for a structured clinical vocabulary: mapping from Yale to the Columbia medical entities dictionary

OBJECTIVE

To examine the issues involved in mapping an existing structured controlled vocabulary, the Medical Entities Dictionary (MED) developed at Columbia University, to an institutional vocabulary, the laboratory and pharmacy vocabularies of the Yale New Haven Medical Center.

DESIGN

200 Yale pharmacy terms and 200 Yale laboratory terms were randomly selected from database files containing all of the Yale laboratory and pharmacy terms. These 400 terms were then mapped to the MED in three phases: mapping terms, mapping relationships between terms, and mapping attributes that modify terms.

RESULTS

73% of the Yale pharmacy terms mapped to MED terms. 49% of the Yale laboratory terms mapped to MED terms. After certain obsolete and otherwise inappropriate laboratory terms were eliminated, the latter rate improved to 59%. 23% of the unmatched Yale laboratory terms failed to match because of differences in granularity with MED terms. The Yale and MED pharmacy terms share 12 of 30 distinct attributes. The Yale and MED laboratory terms share 14 of 23 distinct attributes.

CONCLUSION

The mapping of an institutional vocabulary to a structured controlled vocabulary requires that the mapping be performed at the level of terms, relationships, and attributes. The mapping process revealed the importance of standardization of local vocabulary subsets, standardization of attribute representation, and term granularity.

Evaluation of children's sexual behaviors and incorporation of base rates in judgments of sexual abuse

One hundred sixty-one professionals and 97 undergraduates were asked to (a) prioritize 12 hypothetical CPS cases on the basis of sexual behaviors displayed by children, and (b) estimate the probability of abuse in a single case involving a child who had displayed sexual behavior and came from a population with a known base rate of abuse. When asked to prioritize the 12 cases as "high," "medium," or "low" on the basis of sexual behaviors, professionals were more accurate than students. However, when asked to estimate the probability of abuse in the single case, both professionals and students failed to incorporate base rate information into their decisions. As a result, both groups misestimated the probability of abuse under some circumstances. Professionals' performance on both judgment tasks was unrelated to level of experience with sexual abuse cases.

Analysis of locus heterogeneity in Waardenburg syndrome types 1 and 2 using highly informative microsatellite markers

We performed linkage and locus heterogeneity analyses of Waardenburg syndrome (WS) types 1 and 2 using 9 DNA markers from 2q35-q37, including two highly polymorphic microsatellites very closely linked to the PAX3 candidate gene. None of 5 WS type 2 (WS2) families showed linkage to the PAX3 candidate region. We localized the marker D2S102 to less than 1 cM from PAX3 (lod = 33.7, theta = 0), but a complete absence of crossovers prevented determining whether it maps distal or proximal to PAX3. Study of 14 WS type 1 (WS1) families yielded a maximum lod score of 27.81 at PAX3, theta f = 0.010, theta = 0.007 assuming homogeneity. However, we found significant evidence of locus heterogeneity, with one family initially classified as WS1 unlinked to the PAX3 region. Reevaluation of the clinical features of this family revealed atypical morphology of inner canthi. This produced the appearance of dystopia canthorum and high W-index scores. While our one unlinked WS1 family exhibits atypical canthal morphology, our type 1 families with classic dystopia appear to be homogeneously linked to PAX3. These and other findings identify precautions that need to be addressed before using PAX3-linked markers for diagnostic purposes.

P-glycoprotein expression in chronic lymphocytic-leukemia - association with chemotherapy

P-glycoprotein (PgP), a transmembrane protein, has been associated with multiple drug resistance. We examined 42 patients with chronic lymphocytic leukemia immunohistochemically using the monoclonal antibody JSB-1 to determine the prevalence of PgP expression and its relationship with chemotherapy exposure. Of the 42 patients, 31 (74%) had detectable PgP. No relationship was found between PgP expression, patient age, duration of disease or stage. Moderate and strong intensity staining was found in 22% of untreated patients versus 56% patients treated with chemotherapy (p<0.05). Temporal fluctuations in P-glycoprotein staining intensity was seen in 6 of 7 cases which paralleled the initiation or withdrawal of the therapy.

The relationship of various measures of time urgency to indices of physical health

The degree of association with two general health indices was assessed for three separate measures of time urgency. The Speed and Impatience subscale of the Jenkins Activity Survey was found to have no significant relationships with the health indices. The Time Urgency/Perpetual Activation (TUPA) scale, as well as the Irritability and Impatience scale, did correlate in comparable ways with a majority of the health indicators. A very brief, 2-item impatience subscale of the Irritability and Impatience Scale also correlated with health indices in essentially the same manner as the complete Irritability and Impatience Scale and the TUPA Scale. It was concluded that because of its convenience of administration, the very brief 2-item impatience subscale of the Irritability and Impatience Scale may constitute the instrument of choice for assessing time urgency as it relates to noncardiovascular health. A question is raised regarding whether anger and time urgency constitute separate factors or are aspects of a single behavioral trait.

Regulation of the complement cascade by soluble complement receptor type 1. Protective effect in experimental liver ischemia and reperfusion

The complement cascade was inactivated in a model of rat liver ischemia with the purpose of studying the role of complement in tissue injury after ischemia and reperfusion. Soluble human complement receptor type 1 (sCR1) was administered either in a single dose of 25 mg/kg or in 2 doses of 50 mg/kg i.v. over 24 hr after vascular occlusion. Sham-operated rats, nontreated rats submitted to liver ischemia, and rats pretreated with cobra venom factor and submitted to liver ischemia were used as controls. This experiment consists of the temporary interruption of arterial and portal blood flow to the left lateral and medial lobes of the liver for 45 min, followed by a 24-hr period of follow-up after reperfusion. Liver blood flow and hemoglobin saturation were recorded for 1 hr after declamping, with statistically significant differences between the experimental groups and the untreated control group, which received liver ischemia (P < 0.001). At 24 hr, galactose elimination was assayed as a liver function test; it was significantly better in the sCR1-treated rats when compared with control rats submitted to ischemia (P < 0.01). Alanine aminotransferase levels were also significantly lower in the sCR1-treated rats at 6 and 24 hr (P < 0.05). Complement activity was reduced to 25% and 12.5% of normal rats with the respective doses of sCR1. Immunoperoxidase stainings for C3 and C9 were performed on liver sections; they showed endothelial deposits of C3 and C9 in the control group subjected to ischemia. Few C3 deposits were present in the sCR1 (25 mg/kg)-treated rats, but not in the cobra venom factor or sCR1 (50 mg/kg) groups. These results confirm that complement is inactivated by sCR1 with amelioration of reperfusion injury in the rat liver.

The control of hyperacute rejection by genetic engineering of the donor species

Activation of endogenous complement is inhibited both in the soluble phase and at the membrane surface by a group of structurally similar proteins. A possible solution to hyperacute rejection is to produce donor animals transgenic for human complement regulators. Mouse cells expressing the human complement regulatory proteins decay accelerating factor (DAF) or membrane cofactor protein (MCP) were produced both by hybridoma technology and by transfection with the appropriate cDNAs. The expression of either or both of these products protected the mouse cell from lysis by human (though not rabbit) complement in the presence of naturally occurring human anti-mouse antibody. This effect could be abrogated by the addition of monoclonal antibody against DAF or MCP. Hyperacute rejection of discordant organ xenografts is mediated by human complement. A 6.5 kilobase minigene for DAF has been microinjected into porcine fertilised ova. Forty-five pigs transgenic for human DAF have been produced. Of these, 65% transcribe message. The amount of message produced varied substantially from animal to animal and was independent of copy number integrated. Expression of human DAF on the porcine lymphocyte surface could be detected and this was able to downregulate human complement activation. Amounts of protein expressed on different tissues varied both from pig to pig and within animals from tissue to tissue. The pigs grow and develop normally with no evidence of ill effects due to possession of the transgene.

Lessons learned from a pilot implementation of the UMLS information sources map

OBJECTIVE

To explore the software design issues involved in implementing an operational information sources map (ISM) knowledge base (KB) and system of navigational tools that can help medical users access network-based information sources relevant to a biomedical question.

DESIGN

A pilot biomedical ISM KB and associated client-server software (ISM/Explorer) have been developed to help students, clinicians, researchers, and staff access network-based information sources, as part of the National Library of Medicine's (NLM) multi-institutional Unified Medical Language System (UMLS) project. The system allows the user to specify and constrain a search for a biomedical question of interest. The system then returns a list of sources matching the search. At this point the user may request 1) further information about a source, 2) that the list of sources be regrouped by different criteria to allow the user to get a better overall appreciation of the set of retrieved sources as a whole, or 3) automatic connection to a source.

RESULTS

The pilot system operates in client-server mode and currently contains coded information for 121 sources. It is in routine use from approximately 40 workstations at the Yale School of Medicine. The lessons that have been learned are that: 1) it is important to make access to different versions of a source as seamless as possible, 2) achieving seamless, cross-platform access to heterogeneous sources is difficult, 3) significant differences exist between coding the subject content of an electronic information resource versus that of an article or a book, 4) customizing the ISM to multiple institutions entails significant complexities, and 5) there are many design trade-offs between specifying searches and viewing sets of retrieved sources that must be taken into consideration.

CONCLUSION

An ISM KB and navigational tools have been constructed. In the process, much has been learned about the complexities of development and evaluation in this new environment, which are different from those for Gopher, wide area information servers (WAIS), World-Wide-Web (WWW), and MOSAIC resources.

Detection and prevention of treatable visual failure in general practice: room for improvement?

An ageing population, the introduction of sight test charges and a problem that has never been adequately addressed since the inception of the National Health Service presents general practitioners with the increasing burden of detecting and preventing visual failure which they feel poorly equipped to deal with. Ophthalmology in general practice is a fundamental requirement for the reduction of avoidable visual failure and this is probably especially true for elderly patients and diabetic patients. A postal survey of general practitioners in Brent and Harrow suggests that there is potential for major improvements in the delivery of eye care by general practitioners, often without much additional expenditure (the equipment is there but it is not used) and with minimal training requirements. Simple changes in already existing screening programmes could potentially have an immediate effect on the visual well-being of the community.

Validation of a single point flow cytometric assay for determining P-glycoprotein activity in multidrug resistant cell lines

P-glycoprotein, a transmembrane protein which acts as an energy dependent efflux pump, has been implicated as one mechanism of multidrug resistance (MDR) in human tumours. Commonly employed assays measure P-glycoprotein immunohistochemically or mdr1 messenger RNA. In this study we compared a single point flow cytometric assay for determining activity of P-glycoprotein with cellular expression of P-glycoprotein determined by Western blot. Five cell lines, with varying levels of multiple drug resistance, were incubated with daunorubicin (DNR) in the presence (treated) and absence (control) of cyclosporine or verapamil, agents known to inhibit the activity of P-glycoprotein. The treated cell lines, along with non-treated controls were examined for intracellular concentrations of DNR measured by fluorescence intensity using a flow cytometer. The ratio of fluorescence intensity expressed in the treated/control was used as an index of functional activity of P-glycoprotein. Functional activity of the P-glycoprotein as determined by flow cytometry correlates highly with cellular content of P-glycoprotein measured by western blot (correlation coefficients of r = 0.90-0.98 for the various cell line combinations). This method represents a rapid single point flow cytometric assay which may be suitable for screening clinical samples for P-glycoprotein activity.

Prenatal diagnosis in the 1990s

Prenatal diagnosis has become widely available and detects an increasing variety of birth defects and potentially harmful medical conditions. Many of the studies are complex and must be performed within a specific time period. Most prenatal diagnostic sampling techniques have some degree of risk for the mother or the fetus, and all produce at least transient anxiety. Nurses are involved in identifying families at risk, preparing women for the procedures, providing support, and counseling patients after the results are known; because of this role, nurses need updated information. This review describes current methods for early identification of a potential problem, discusses a variety of prenatal diagnostic procedures, reviews the most common types of laboratory studies, and introduces future trends in the field of prenatal diagnosis.

Cytokine activity after allogeneic bone marrow transplantation. V. Analysis of IL-2 and IFN production by isolated CD4+ and CD8+ cells

Previous studies from this laboratory have shown that PBMC from recipients of an HLA-identical sibling bone marrow transplant produce levels of IL-2 which are 10-100-fold lower than those produced by the same number of PBMC from healthy controls, whereas production of IFN-gamma is normal. The present study examined IL-2 and IFN production over a range of cell numbers for PBMC and for isolated CD4+ and CD8+ cells for controls and marrow transplant recipients. There was a 5-fold lower IL-2 production in marrow transplant recipient CD8+ cells compared with equivalent numbers of control cells, whereas no difference was found in IL-2 production by CD4+ cells. In contrast, IFN production by CD4+ cells from marrow transplant recipients was 4-fold higher than in controls, whereas CD8+ cells from both populations produced similar amounts of IFN. When the observed production of cytokine by PBMC was compared with the expected production based on the CD4+ and CD8+ content of the PBMC, control values were similar, but the expected values for both cytokines were approximately 2-fold higher than the observed values for marrow transplant recipients. The results suggest that the capacity of T cells from marrow transplant recipients to produce IL-2 and IFN is not impaired, but that the frequency of cytokine-producing cells may be reduced, and that a negative interaction present in recipient PBMC, eliminated by isolating T-cell subsets, is responsible for the observed low levels of cytokine production.

The factor analytic structure of seven physical CHD risk factors: a replication study

An attempt was made to replicate the results of an earlier confirmatory factor analysis of the seven traditionally employed physical risk factors for CHD. As with the first investigation, a two-factor solution was confirmed; only family history loaded on factor 1; the remaining six risk variables (smoking, serum cholesterol, blood pressure, diet, exercise, and weight control) comprised factor 2. These findings may reflect a broad personality trait, i.e., generalized lack of self-control, which could underlie much CHD risk not associated with a family history of heart disease. Implications are drawn for research and practice in the areas of cardiac rehab and prevention.

Criterion validity and reliability of the SF-36 in a population sample

This study aimed to determine the criterion validity of the Short Form 36 health survey questionnaire (SF-36) in a large community sample, and to explore the instrument's internal consistency and validity in groups reporting different levels of ill-health. A postal survey was undertaken using a questionnaire booklet, containing the SF-36 and a number of other items concerned with lifestyles and illness. The questionnaire booklet was sent to 13,042 randomly selected subjects between the ages of 18-64 years, drawn from Family Health Services Authority (FHSA) computerized registers for Berkshire, Buckinghamshire, Northamptonshire and Oxfordshire. This paper is based upon the 9332 (72%) responses gained. Scores for the functional status and well-being scales of the SF-36 were used as outcome measures. The response rate for the questionnaire booklet was 72%. Internal consistency of domains was found to be high, both for the sample as a whole, and when broken down by specific subgroups. Criterion validity was assessed by comparing scores for the seven multi-item dimensions assessing functional status and well being with a single global health question. The global question was the first item of the SF-36 and asks respondents to evaluate their health 'overall'. Statistically significant trends were observed for decreasing SF-36 scores (i.e., those indicating greater health problems) with worsening self-rated general health. These results provide further psychometric evidence for the use of the SF-36 when used with groups reporting varying extents of ill-health.

Stuttering therapy with British-Asian children. I: A survey of service delivery in the United Kingdom

The results of a UK survey of speech and language therapy services offered to Asian children and adolescents who stutter are set in the context of current therapy approaches favoured in the UK. Eighty-seven speech and language therapists from the major centres of Asian population in the UK completed a postal questionnaire. This yielded data on: service delivery to stuttering children in general; the size and nature of the Asian populations served; therapists' own cultural backgrounds; steps taken by therapists to increase their skill in this area; interpreter services available; changes made to usual working practices aimed at accommodating the cultural needs of Asian clients. The results revealed a service mostly provided by non-specialist therapists, who treated small numbers of both stuttering and Asian clients. Therapists were serving clients from up to four different cultural and linguistic backgrounds, yet access to interpreter services was poor. Therapists were on the whole poorly trained and equipped to treat Asian clients. A range of changes to working practices are described, but no cohesive approach was apparent. The issues involved in appropriate and accessible service delivery are discussed.

Stuttering therapy with British-Asian children. II: Speech and language therapists' perceptions of their effectiveness

This paper tested hypotheses arising from the literature on the treatment of stuttering in British-Asian children and adolescents, using data obtained from a postal questionnaire completed by 87 therapists. The results showed therapists treating lower numbers of Asian clients than expected, but perceiving their therapy to be less effective with their Asian clients than with their British ones. The variables affecting therapists' perceived success were not those expected. Greater experience with Asian clients did not increase perceived success, nor did Asian therapist and client sharing broadly the same cultural background guarantee success. A satisfactory interpreter service did not lead to a higher perceived success rate, nor did postgraduate training or making special changes to usual working practices. On the contrary, therapists in the last two categories were less likely to perceive success with their Asian clients. Therapists identified a very wide range of cultural factors needing special consideration in therapy, but consensus centred around parental attitudes to stuttering and to therapy.

Differences between American Indian and non-Indian children referred for psychological services

The physical and social characteristics of 60 American Indian children referred for psychological services were compared to those of 60 matched, non-Indian controls. Data were obtained from detailed records available in a multidisciplinary, medical school-related child study clinic. Indian children exhibited more health and social risk factors, but were superior to non-Indians on a variety of motor variables. Interpretations are offered concerning better psychological services for American Indian children based on better understanding of their possible exposure to physical health and social risks which may be related to psychological development.

Ribozyme-mediated cleavage of the bcr/abl transcript expressed in chronic myeloid leukemia

The bcr/abl transcript is specifically expressed in the hematopoietic cells of patients with chronic myeloid leukemia (CML). The Haseloff and Gerlach model was used to design a ribozyme targeted to this transcript. When tested against a synthetic substrate covering the translocation sequence, the ribozyme exhibited site specificity and an absolute requirement for divalent metal ions. Cleavage of the normal bcr was also noted but at a reduced efficiency compared to that exhibited for the bcr/abl substrate. Importantly, cleavage of the full-length bcr/abl mRNA was achieved at physiologic temperature, demonstrating effective ribozyme-mediated cleavage.

The VCOP Scale: a measure of overprotection in parents of physically vulnerable children

A scale is developed for measuring the overprotecting vs. optimal developmental stimulation tendencies for parents of physically "vulnerable" children. A series of items were administered to parents whose parenting techniques had been rated as either highly overprotective or as optimal by a group of MDs and other professionals. Correlations were estimated between each of the items and parental tendencies as rated by professionals. Twenty-eight items were selected that provided maximum prediction of over-protection. The resulting R2 was extraordinarily high (.94). Coefficient alpha and test-retest coefficients were acceptable. It is hoped that release of the new instrument (VCOPS) at this time will allow others to join in determining the clinical and experimental validity of this scale.

Short form 36 (SF36) health survey questionnaire: normative data for adults of working age

OBJECTIVES

To gain population norms for the short form 36 health survey questionnaire (SF36) in a large community sample and to explore the questionnaire's internal consistency and validity.

DESIGN

Postal survey by using a booklet containing the SF36 and several other items concerned with lifestyles and illness.

SETTING

The sample was drawn from computerised registers of the family health services authorities for Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire.

SAMPLE

13,042 randomly selected subjects aged 18-64 years.

MAIN OUTCOME MEASURES

Scores for the eight health dimensions of the SF36.

RESULTS

The survey achieved a response rate of 72% (n = 9332). Internal consistency of the different dimensions of the questionnaire was high. Normative data broken down by age, sex, and social class were consistent with those from previous studies.

CONCLUSIONS

The SF36 is a potentially valuable tool in medical research. The normative data provided here may further facilitate its validation and use.

International file: the finer points of working in England's ORs

The fundamental philosophy behind quality patient care is international; the specialised area of OR nursing should be less susceptible to international differences. Yet, the experience of moving to a different country reveals the extent of the actual cultural and professional variations available. The subtle, yet real, practical differences observed by a Canadian OR nurse, after working in England for two years, are examined.

Prevalence of glaucoma in the west of Ireland

County Roscommon in the west of Ireland is a relatively remote rural area whose population of 55,000 is served by two community medical ophthalmologists and three optometrists. Eye surgical services are not available within the county. In order to assess the needs of the community for prevention of blindness from glaucoma, a simple random sample of the population of County Roscommon was taken for a community based glaucoma survey. A total of 2186 people over the age of 50 were examined which represented a 99.5% response rate. The high response rate was achieved by the community basis of the study and vigorous follow up of non-attenders. Intraocular pressure was measured using applanation tonometry, disc evaluation by both direct ophthalmoscopy and stereoscopic biomicroscopy, and visual field analysis using the Henson CFS 2000 and experimental computer controlled video perimetry. Diagnostic criteria were consistent with the preferred practice pattern of the American Academy of Ophthalmology. A crude prevalence of approximately 2% for primary open angle and normal tension glaucoma was found. The population profile of intraocular pressure showed a pattern which decreased with increasing age unlike the Framingham and Ferndale studies but similar to Japanese data.

Platelet activating factor (PAF) enhances mitosis in preimplantation mouse embryos

Preimplantation mouse embryos were used to determine whether the reported significant increase in embryo metabolism and viability achieved through supplementation of the culture medium with the ether phospholipid 1-o-alkyl-2-acetyl-sn-glycero-3-phosphocoline (platelet activating factor, PAF) is attributable to an enhanced rate of mitosis. Blastocyst-stage embryos cultured in the presence of 0.186 to 18.6 microM exogenous PAF had a significantly (P < 0.01) higher mitotic index (the proportion of cells arrested in metaphase following incubation in colchicine) than those cultured without PAF. At the 8-cell stage, 29% more blastomeres were in metaphase in the PAF-treated group (P < 0.01) 8 h after the addition of colchicine, but by 16 h there was no difference between groups; thus, PAF increased the rate at which cells entered metaphase but did not increase the total number. The mitotic index showed a negative correlation with the number of cells within blastocysts. PAF had a significantly (P < 0.01) greater impact on the mitotic index of blastocysts with fewer cells. The action of PAF was specific, being completely blocked by the PAF-receptor antagonist WEB 2086 (33 microM). In the absence of exogenous PAF the mitotic index was lower with WEB 2086 than without, suggesting inhibition of the action of endogenous embryo-derived PAF. These results show that PAF stimulates the rates at which cells within the preimplantation mouse embryo enter metaphase in vitro and suggest that it would decrease their doubling time, perhaps accounting for the embryotrophic actions of PAF.