Trends in cancer incidence and mortality in Scotland: description and possible explanations

Secular and cohort trends in mortality from cancer in Scotland during 1953-93, and incidence during 1960-90, were analysed using individual records from the national mortality and registration files. For certain cancer sites, the secular analyses of mortality were extended back to 1911 by use of published data. Mortality from cancer at older ages in Scotland has increased over the last 40 years. In each sex, this trend has been dominated by the effects of smoking: all-cancer rates and rates of lung cancer, now the most common fatal cancer in men and in women in Scotland, reached a peak in the cohort of men born at the turn of the century and the cohort of women born in the 1920s. For much of the period, the Scottish all-age rates of lung cancer were the highest reported in the world; they are now decreasing on a secular basis in men, but are still increasing in women. There have also been large increases at older ages in the incidence and mortality rates for cancer of the prostate in recent years. bladder cancer, nervous system cancer, non-Hodgkin's lymphoma, myeloma and leukaemia; for each there is likely to be a considerable artefactual element to the increase, with differing degrees of possibility that there may in addition be an element of real increase. Substantial decreases in mortality at all ages have occurred for stomach and colorectal cancers and substantial increases at all ages for pleural cancer and melanoma. Rates of mortality from breast cancer, the most common cancer in women in Scotland, have generally increased over the past 80 years; a temporary cessation in this upward trend occurred in the years during and after the Second World War, and recently rates have turned downward, probably at least in part because of better treatment. Mortality from ovarian cancer, the second most common reproductive-related female tumour in Scotland, has also increased at older ages. At younger ages, mortality from cancer in Scotland has decreased, especially in men, whereas incidence has not. This divergence, which has been a consequence of better treatment, has occurred especially for cancers of the testis and ovary, Hodgkin's disease and leukaemia. There have been increases at young adult ages, however, in both mortality from and incidence of oral and pharyngeal, oesophageal and laryngeal cancers in men, and melanoma and non-Hodgkin's lymphoma in each sex. Cervical cancer rates at young ages also increased, but this trend has reversed for incidence in the most recent birth cohorts. Incidence rates have also increased for testicular cancer in young adults and leukaemia in children. With the possible exceptions of non-Hodgkin's lymphoma and childhood leukaemia, the increasing rates are likely largely to reflect real rises in incidence, and they highlight the need for investigation of the causes of these cancers, and, when causes are known, for preventive action.

Time course of stomach mineralization, plasma, and urinary changes after a single intravenous administration of gadolinium(III) chloride in the male rat

In a previous experiment it was reported that the intravenous administration of gadolinium chloride (GdCl3) to rats results in a discrete band of interstitial mineralization in the fundic glandular mucosa of the stomach. To investigate the time course for the development of this lesion and its relationship to plasma calcium and phosphate concentrations, 2 experiments were carried out in male Sprague-Dawley rats given a single intravenous dose of 0.07 mmol/kg GdCl3. Plasma calcium and phosphate concentrations approximately doubled between 30 min and 12 hr postdose but had regressed back to near normal values by 24 hr. However, there were no observable clinical signs in treated animals. Histologically, there was progressive mineralization of the lamina propria of the neck region of the fundic glands from 6 hr postdose, forming a distinctive mineral band by 12 hr postdose. At 7 and 14 days postdose the mineral deposits were accompanied by mucous cell hyperplasia, interstitial fibrosis, and a very sparse infiltration of inflammatory cells. By 56 days postdose only occasional mineral deposits remained. Transmission electron microscopy showed mineral first nucleated on collagen in the interstitium, but there was no evidence of cell necrosis. X-ray microanalysis showed that the interstitial mineral was composed of calcium and phosphate in the form of hydroxyapatite; gadolinium (Gd) was only very rarely identified. These findings are consistent with metastatic mineralization. The source, cause, and the exact nature of the excess plasma calcium and phosphate are unknown, and the possible significance of this effect for clinical use of Gd-containing chelates in nuclear magnetic resonance imaging requires further investigation.

Inducible nitric oxide synthase demonstrated in allergic and irritant contact dermatitis

Eight allergic patch test reactions, eight irritant skin reactions induced by 3% sodium lauryl sulphate and six normal controls were biopsied. Biopsies were immunohistochemically stained with a mouse monoclonal antibody to inducible nitric oxide synthase (iNOS), and staining was quantified by computerised image analysis. Human chondrocytes induced to express iNOS were used as a positive control. A significant increase in iNOS was found in both irritant and allergic contact dermatitis. There were no differences in the distribution of expression of iNOS. The antibody used was confirmed by Western blotting not to cross-react with the endothelial isoform of nitric oxide synthase (NOS) but did cross-react with a 150 kDa protein, which may be neuronal NOS or an isoform of neuronal NOS.

Acute otitis media and otitis media with effusion in children with bacterial meningitis

Acute otitis media and otitis media with effusion (OME) have often been observed in children with bacterial meningitis. OME has also been proposed as the mechanism of reversible hearing loss after meningitis. In this controlled study, children with acute bacterial meningitis were studied using auditory brainstem responses (ABR), otoacoustic emissions, tympanometry and otoscopy. An age- and sex-matched control was recruited for each patient and the incidence of acute otitis media and OME was compared between the two groups. One hundred and twenty-four children with meningitis were studied. Ninety-two children (74 per cent) had meningococcal meningitis. Five patients (4 per cent) had conductive hearing loss (ABR threshold > or = 30 dB HL) at the time of discharge from hospital. None of the patients or controls had acute otitis media. Patients and controls were well matched for risk factors for OME and the prevalence of middle ear effusion in patients and controls was 7.2 per cent and 11.3 per cent respectively. The relative risk of OME in the children with meningitis was 0.64 (95 per cent confidence interval 0.29 to 1.42). After nine months, three of the five children with meningitis and conductive hearing loss had regained normal hearing. In contrast to previous reports, there was no relationship between bacterial meningitis and acute otitis media or OME in this study. Nevertheless, coincidental conductive hearing defects were identified as the cause of reversible hearing loss in three patients.

Leukemia-associated retinoic acid receptor alpha fusion partners, PML and PLZF, heterodimerize and colocalize to nuclear bodies

In acute promyelocytic leukemia (APL), the typical t(15;17) and the rare t(11;17) translocations express, respectively, the PML/RARalpha and PLZF/RARalpha fusion proteins (where RARalpha is retinoic acid receptor alpha). Herein, we demonstrate that the PLZF and PML proteins interact with each other and colocalize onto nuclear bodies (NBs). Furthermore, induction of PML expression by interferons leads to a recruitment of PLZF onto NBs without increase in the levels of the PLZF protein. PML/RARalpha and PLZF/RARalpha localize to the same microspeckled nuclear domains that appear to be common targets for the two fusion proteins in APL. Although PLZF/RARalpha does not affect the localization of PML, PML/RARalpha delocalizes the endogenous PLZF protein in t(15;17)-positive NB4 cells, pointing to a hierarchy in the nuclear targeting of these proteins. Thus, our results unify the molecular pathogenesis of APL with at least two different RARalpha gene translocations and stress the importance of alterations of PLZF and RARalpha nuclear localizations in this disease.

Peripheral adenosine 5'-triphosphate enhances nociception in the formalin test via activation of a purinergic p2X receptor

The pronociceptive effects of adenosine 5'-triphosphate (ATP) were examined in the low concentration formalin model (0.5%) by coadministration of ATP, ATP analogs (alpha,beta-methylene-ATP and 2-methylthio-ATP) and antagonists (suramin, pyridoxalphosphate-6-azophenyl-2',4'-disulfonic acid) with formalin and determining effects on the expression of flinching behaviours. Coadministration of ATP (5-500 nmol) with formalin enhanced phase 2 (12-60 min after injection) but not phase 1 (0-10 min after injection) responses. alpha,beta-methylene-ATP (0.5-50 nmol) but not 2-methylthio-ATP (50-500 nmol) produced a similar enhancement of activity, generating an order of potency of alpha,beta-methylene-ATP, ATP >> 2-methylthio-ATP. This enhancement was primarily expressed in the latter part of phase 2, 30-60 min after injection. Coadministration of suramin 50-500 nmol, a non-selective P2X and P2Y purinoceptor antagonist and pyridoxalphosphate-6-azophenyl-2',4'-disulfonic acid 5-500 nmol, a selective P2X purinoceptor antagonist, dose-dependently inhibited the augmentation of the formalin response by ATP 50 nmol, but did not reduce the response to formalin itself. Pretreatment for 30 min with higher doses of suramin inhibited the response to formalin (0.5%, 1.5%) and this appeared to be by a systemically mediated action as it was seen following administration into the contralateral paw. The results of this study provide evidence in support of a P2X purinoceptor mediated augmentation of the pain signal by ATP. The delayed time-course of the effect suggests that it may occur in concert with other mediators that are recruited by the inflammatory process, rather than reflecting a direct depolarization of sensory nerves. Other behavioural paradigms may be required to examine the fast onset, direct effect. Suramin appears to exert both local and systemic effects on the expression of pain behaviours in response to formalin.

Community action for health promotion: a review of methods and outcomes 1990-1995

OBJECTIVE

Our objective was to explore the effectiveness of community action as a strategy for health promotion, through a critical review of five years of community action evaluation literature.

METHODS

Community action was defined as a health promotion, program that involved the community in implementation and control of the process of the program. Criteria for scientific evaluation of programs were proposed for sampling and control procedures, reliability and validity of instruments, analysis techniques, and specification of details of the intervention. A critical review of the literature, located by an on-line and related reference search, was undertaken for community action aimed at reducing cancer and cardiovascular disease, between January 1990 and May 1995.

RESULTS

None of seven community action studies (17 articles) that examined cancer risk factors fulfilled all the criteria for rigorous scientific evaluation. The most methodologically adequate cancer study, the COMMIT intervention, had only a moderate degree of success in reducing community smoking rates. Similarly, none of the six studies (25 articles) on cardiovascular disease fulfilled all the criteria. The results for the most methodologically adequate study, the Minnesota Heart Health Program, were disappointing, with strong secular trends preventing adequate assessment of the intervention effect.

CONCLUSIONS

The finding that none of the reviewed studies met all evaluation criteria was due to several factors, including political considerations, feasibility, and the continued evolution of the science of evaluation in health promotion. Some important questions are posed for researchers by the failure of methodologically superior projects, such as COMMIT, to show major gains in reducing health risk behaviors.

Gadolinium chloride toxicity in the rat

Groups of 10 male and 10 female Sprague-Dawley rats were given a single intravenous injection of gadolinium chloride solution at dosages of 0 (saline vehicle), 0.07, 0.14, and 0.35 mmol/kg. Apart from 1 top-dose female, which died during dosing, 5 rats/sex/ group were necropsied 48 hr postdose, and the remaining 5 rats/sex/group were necropsied 14 days postdose. Macroscopic, hematological, and clinical chemistry analyses were undertaken on all animals that were necropsied. Histopathological examination was undertaken on all organs from high-dose and control animals necropsied 48 hr postdose and on tissues that showed treatment-related changes from all other rats necropsied either 48 hr or 14 days postdose. Major lesions related to gadolinium chloride administration consisted of mineral deposition in capillary beds (particularly lung and kidney), phagocytosis of mineral by the mononuclear phagocytic system, hepatocellular and splenic necrosis followed by dystrophic mineralization, mineralization of the fundic glandular mucosa in the absence of necrosis followed by mucous cell hyperplasia, decreased platelet numbers and increased prothrombin time, and activated partial thromboplastin time. Electron microscopy and x-ray microanalysis of the spleen and liver revealed electron-dense deposits in splenic macrophages, Kupffer cells, and hepatocytes composed of gadolinium, calcium, and phosphate.

Assessment of faculty development program outcomes

BACKGROUND AND OBJECTIVES

More and better research is needed about the effectiveness of faculty development programs. Increasingly, government leaders in Congress and the Administration expect comprehensive outcome and impact evaluation as justification for federal finding. This paper summarizes outcomes reported and methods used in published studies of faculty development programs since 1980.

Outcomes of three part-time faculty development fellowship programs

BACKGROUND AND OBJECTIVES

Part-time faculty development fellowship programs have trained large numbers of new physician faculty for family medicine education programs. This study reviews data from three part-time fellowship programs to determine how well the programs train new faculty and the academic success of fellowship graduates.

METHODS

Part-time fellowship programs at Michigan State University, the University of North Carolina, and the Faculty Development Center in Waco, Tex, sent written surveys to graduates as part of routine follow-up studies. Graduates were asked to report their current status in academic medicine, how they spend their time, measures of academic productivity, and assessments of how well their training prepared them for their current academic positions. Data were complied at each institution and sent to Michigan State University for analysis.

RESULTS

The majority of graduates (76%) have remained in their academic positions, and half (49%) teach in medically underserved settings. Graduates report high levels of satisfaction with the training they received. Thirty-two percent of graduates have published peer-reviewed articles, and almost 50% have presented at peer-reviewed meetings.

CONCLUSIONS

Part-time fellowship programs have been successful at training and retaining large numbers of new faculty for family medicine.

Generic inhaled salbutamol versus branded salbutamol. A randomised double-blind study

Generic substitution of salbutamol lags behind that of other drugs in Scotland and a negative perception by both patients and doctors may explain this. The aim of this study was to assess whether, in clinical practice, there was any difference in efficacy between branded salbutamol (Ventolin) and a generic preparation. Asthmatic patients using a Ventolin metered-dose inhaler at least twice a day for symptom relief were entered into a double-blind cross-over study, comparing Ventolin, blinded Ventolin and a generic salbutamol in random order for two weeks each. Daily peak flows, inhaler use and bronchodilator response were recorded. At the end of each treatment period patients rated their inhaler against their usual Ventolin on a 5-point scale. Forty patients were entered into the study; 90% received 1000 micrograms or more of inhaled steroids per day. Eleven patients dropped out during the run-in phase. In the remaining 29 patients, no significant difference between treatments could be found in any of the objective parameters measured. Fifty-five per cent of patients said they could detect a difference between the inhalers, and 45% noted a difference between their usual Ventolin and the open or blinded Ventolin. This study showed clinical equivalence between a generic and branded salbutamol. Patients' own assessment of their relief inhaler seems to be influenced by factors other than efficacy. The study highlights that careful encouragement is required when changing to a generic product and has particular implications for the forthcoming conversion to CFC-free products.

Thinking of England and taking care: family building strategies and infant mortality in England and Wales, 1891-1911

"Debates concerning the origins and development of the late nineteenth- to early twentieth-century declines in marital fertility and infant mortality in England and Wales have been centred largely on the material provided by answers to the ¿special' questions in the 1911 census. In their published form these figures have restricted researchers to an examination of large scale geographic and social class differences in the levels and rates of decline of the two phenomena. This paper outlines research conducted on a sample of individual census returns from the 1911 census. From this data it becomes clear that for Victorian and Edwardian England ¿where one lived' was rather more important than ¿who one was' in determining both family building strategies and the survival of those children born."

Hearing loss during bacterial meningitis

OBJECTIVE

To determine the natural history and pathogenesis of hearing loss in children with acute bacterial meningitis.

DESIGN

Multicentre prospective study.

SETTING

21 hospitals in the south and west of England and South Wales.

SUBJECTS

124 children between the ages of 4 weeks and 16 years with newly diagnosed bacterial meningitis.

METHODS

Children underwent repeated audiological assessment with the first tests being performed within six hours of diagnosis. By using a combination of otoacoustic emissions, auditory brainstem responses, and tympanometry the differences between cochlear, neural, and conductive defects were distinguished.

RESULTS

Ninety two children (74%) had meningococcal and 18 (15%) had pneumococcal meningitis. All cases of hearing loss were apparent at the time of the first assessment. Three children (2.4%, 95% confidence interval (CI) 0.5 to 6.9%) had permanent sensorineural hearing loss. Thirteen children (10.5%) had reversible hearing loss of whom nine had an impairment that resolved within 48 hours of diagnosis. It is believed that this "fleeting' hearing loss has not been reported previously. The cochlea was identified as the site of the lesion in both the permanent sensorineural and reversible impairments. Hearing loss was more common in children who had been ill for more than 24 hours (relative risk 2.72; 95% CI 0.93 to 7.98).

CONCLUSIONS

Sensorineural hearing loss developed during the earliest stages of meningitis. Permanent deafness was rare but 10% of the patients had a rapidly reversible cochlear dysfunction. This may have progressed to permanent deafness if the patients had not been treated promptly.

Local anesthesia for circumcision: which technique is most effective?

BACKGROUND AND OBJECTIVES

Circumcision is the most commonly performed surgical procedure in the United States, and it is painful. Several investigators have independently documented the reliability and safety of local anesthesia in eliminating the pain associated with circumcision. Investigations have not, however, been conducted to determine which technique is most effective in reducing the pain of the procedure. This study compares the techniques of local anesthesia for circumcision to determine which technique most safely and reliably reduces pain.

METHODS

Fifty-six infants being circumcised were randomly assigned to one of three groups according to anesthesia technique: (1) distal branch block, (2) root block, and (3) subpubic block. Change in heart rate and oxygen saturation, as well as cry response, were recorded. Heart rate and oxygen saturation differences were analyzed utilizing Student's t test, whereas cry response was analyzed using the chi-square test.

RESULTS

We discontinued using the distal branch block technique during the study because we were concerned about possible untoward outcomes. As a result, only data from the circumcisions of the 42 infants who were assigned to the root block and subpubic block groups were analyzed. The dorsal penile nerve root block more reliably reduced the pain of circumcision than did the subpubic technique (P = 0.05). There were no serious complications with any of the techniques in this study.

CONCLUSIONS

Compared with distal branch block and subpubic block techniques, nerve block at the penile root most reliably and safely eliminated the pain of circumcision.

Collegial networking and faculty vitality

BACKGROUND

This research explored the relationship between collegial networking and faculty "vitality" among graduates of the family medicine faculty development fellowship at the University of North Carolina at Chapel Hill. Faculty vitality was defined by retention in full-time teaching, job satisfaction, academic activity, and contributions to the discipline.

METHODS

A questionnaire was mailed to 170 family physician graduates of the 1980-1992 fellowship classes. After a mail and telephone follow-up, the response rate was 85%. Data were collected on career history, professional interests, professional relationships, assessment of fellowship, and professional activities.

RESULTS

Respondents with collegial networks were more likely to participate in several academic activities and were more likely to remain in full-time teaching. No association was found between collegial networks and satisfaction or contributions to the discipline. There were only small differences in effect between intra-departmental and extra-departmental collegial networks. Stratification by program type and gender revealed no evidence of effect modification or confounding.

CONCLUSIONS

Collegial networks influence some aspects of faculty vitality, particularly retention in full-time teaching. Further research is needed to fully understand its impact.

DNA fingerprinting of benign and malignant breast lesions

Paired blood and breast tissue samples from 96 patients undergoing surgical excision of a breast lesion were subjected to DNA fingerprint analysis using the minisatellite probes 33.6 and 33.15. The 'fingerprints' of the blood and breast DNA were compared. DNA fingerprint changes seen were classified as band additions, band deletions or changes in band intensity. Significantly more DNA fingerprint changes were seen in malignant than in benign lesions (probe 33.6, P<0.01; probe 33.15, P=0.01; both probes, P = 0.04). The frequency of the changes detected in the breast cancers was unrelated to tumour grade or the presence of invasion. DNA ploidy was measured in 70 of the breast carcinomas. DNA fingerprint changes were seen in 41 of these, but flow cytometry detected aneuploidy in only 29 tumours (P=0.04). The DNA fingerprinting technique is unlikely to be useful in differentiating between benign and malignant breast lesions as changes were detected in one of the fibroadenomas studied. However, it may be a useful technique in screening tumour DNA for abnormalities suitable for more detailed analysis.

Knowledge of cancer risk reduction practices in rural towns of New South Wales

The Australian Cancer Society has published guidelines for recommended risk reduction strategies for breast, cervical, smoking-related and skin cancer. While knowledge may not be sufficient for change, it is argued to be necessary for change to occur. A measure of the level of health knowledge in the community can be useful for health promotion practitioners, identifying where health messages are not reaching their proposed targets. Our aims were to examine the level of knowledge about risk reduction practices for breast, cervical, smoking-related and skin cancers, for a rural New South Wales sample, and to examine sex and age effects on knowledge levels. A survey of 2846 women and 1732 men from rural New South Wales, which used an unprompted recall strategy, revealed some notable deficits in recall of cancer risk reduction practices: only 26 per cent of women identified mammograms as a risk reduction strategy for breast cancer; only 5 per cent of women knew at which ages mammograms should start and stop; only 6 per cent of women could identify when Pap tests should be discontinued; less than half of the sample could identify common solar protection strategies; and less than one-third of people identified passive smoking as a lung cancer risk.

How family influences practice of obstetrics. Do married women family physicians make different choices?

PURPOSE

To examine the influence of family, past and current, on married women family physicians' and to understand why and how some women continue to practise obstetrics.

PARTICIPANTS

Purposive sample of nine married women family physicians who currently practise obstetrics.

METHOD

Qualitative in-depth interviews.

FINDINGS

Analysis identified four main influences of family on participants' practice of obstetrics: family of origin, transitions in the life cycle, children, and the marital relationship.

CONCLUSIONS

These women described how they combined the roles of wife, mother, daughter, sister, and doctor. Family was a powerful influence throughout their practice lives. Finding a balance between the demands of practice, particularly obstetrics, and family relationships was an ongoing process. The process was also influenced by transitions in the life cycle.

Epitope analysis of the murine p53 tumour suppressor protein

The identification and characterisation of the p53 tumour suppressor has relied extensively on the use of immunological reagents. To facilitate further characterisation of the murine p53 protein (Mp53), and its interaction with other proteins, we have characterised the antigenic sites of Mp53 in fine detail. Using an overlapping Mp53 peptide library we report the identification by Pepscan ELISA of the epitopes of nine antibodies. We have also used this technique to determine whether corresponding epitopes were present in a human p53 (Hp53) peptide library. This comparison was extended to include polyclonal sera of mice immunized with either Mp53 or Hp53, to compare the overall range of antigenic sites. The range of antigenic sites identified by polyclonal sera is very similar, although the N-terminus of Mp53 is clearly not an immunodominant region, in contrast to the N-terminus of Hp53. However, the N-terminus of Mp53 is immunogenic in rabbits as demonstrated by the Pepscan ELISA of CM5 serum (a rabbit anti-Mp53 serum used in analysing p53 expression in mice). Since, very few new antigenic sites were identified in either Mp53 or Hp53, new approaches will have to be employed to identify novel immunological reagents against human and murine p53.

Consent form readability in university-sponsored research

BACKGROUND

Consent forms are required in most biomedical research involving human subjects. In recent years, a number of studies from different disciplines have reported problems related to consent form readability.

METHODS

We analyzed 284 consent forms submitted to and approved by five institutional review boards (IRBs) (schools of Medicine, Nursing, Academic Affairs, Dentistry, and Public Health) at one university and one IRB at another. We examined consent form readability scores and factors that might relate to readability.

RESULTS

The average reading level of all consent forms was high: 12.2, which corresponds roughly to a 12th-grade reading level. Less than 10% of all consent forms were written at a 10th grade reading level or below. Thirty-two percent of all consent forms had no evidence of revisions, and less than 2% of consent forms were revised more than once. Readability scores were not related to consent form revisions, the type of IRB, the year of study, or the university where the research was conducted.

CONCLUSIONS

Poor readability of consent forms probably occurs in all university-related research. We recommend that IRBs require readability checks for research consent forms before researchers submit their proposals to an IRB.

Neurotoxin-induced lesions to central serotonergic, noradrenergic and dopaminergic systems modify caffeine-induced antinociception in the formalin test and locomotor stimulation in rats

Our study examined the effects of neurotoxin-induced lesions to central 5-hydroxytryptamine (5-HT), noradrenaline (NA) and dopamine (DA) systems on antinociception by caffeine in the formalin test and on locomotor stimulation by caffeine. Locomotor activity was determined simultaneously with responses to formalin, although in some studies, scores were derived in the absence of formalin. Rats were tested 10 to 12 days after toxin administration, and amine levels in brain regions and the spinal cord determined at the end of the experiment. Intracerebroventricular 5,7-dihydroxytryptamine (+/- desipramine) (which depleted central 5-HT systems) inhibited antinociception by caffeine but had no effect on locomotor stimulation. Intracerebroventricular 6-hydroxydopamine (which depleted NA in brain and spinal cord and DA in brain) augmented both antinociception and locomotor stimulation by caffeine. Both effects were due to NA depletion as they were mimicked by microinjection of 6-hydroxydopamine into the locus ceruleus that selectively depleted NA, not by intracerebroventricular 6-hydroxydopamine with desipramine that selectively depleted DA. In the absence of formalin, locus ceruleus lesions no longer had a significant effect on locomotor stimulation. Phentolamine, an alpha-adrenergic antagonist, inhibited caffeine-induced locomotor stimulation in the absence of formalin. These neurotoxin-induced lesions reveal an involvement of central 5-HT and NA (but not DA) systems in antinociception, and an involvement of central NA (but not 5-HT or DA) systems in locomotor stimulation. There appears to be an interrelationship between noxious stimulation and the expression of locomotor activity.

Amino-terminal protein-protein interaction motif (POZ-domain) is responsible for activities of the promyelocytic leukemia zinc finger-retinoic acid receptor-alpha fusion protein

Promyelocytic leukemia zinc finger-retinoic acid receptor a (PLZF-RARalpha), a fusion receptor generated as a result of a variant t(11;17) chromosomal translocation that occurs in a small subset of acute promyelocytic leukemia (APL) patients, has been shown to display a dominant-negative effect against the wild-type RARalpha/retinoid X receptor alpha (RXRalpha). We now show that its N-terminal region (called the POZ-domain), which mediates protein-protein interaction as well as specific nuclear localization of the wild-type PLZF and chimeric PLZF-RARalpha proteins, is primarily responsible for this activity. To further investigate the mechanisms of PLZF-RARalpha action, we have also studied its ligand-receptor, protein-protein, and protein-DNA interaction properties and compared them with those of the promyelocytic leukemia gene (PML)-RARalpha, which is expressed in the majority of APLs as a result of t(15;17) translocation. PLZF-RARalpha and PML-RARalpha have essentially the same ligand-binding affinities and can bind in vitro to retinoic acid response elements (RAREs) as homodimers or heterodimers with RXRalpha. PLZF-RARalpha homodimerization and heterodimerization with RXRalpha were primarily mediated by the POZ-domain and RARalpha sequence, respectively. Despite having identical RARalpha sequences, PLZF-RARalpha and PML-RARalpha homodimers recognized with different affinities distinct RAREs. Furthermore, PLZF-RARalpha could heterodimerize in vitro with the wild-type PLZF, suggesting that it may play a role in leukemogenesis by antagonizing actions of not only the retinoid receptors but also the wild-type PLZF and possibly other POZ-domain-containing regulators. These different protein-protein interactions and the target gene specificities of PLZF-RARalpha and PML-RARalpha may underlie, at least in part, the apparent resistance of APL with t(11;17) to differentiation effects of all-trans-retinoic acid.

Linear growth of very young asthmatic children treated with high-dose nebulized budesonide

The aim of this open study was to observe linear growth in young children with asthma treated with nebulized budesonide. Infants and young children (< 3 years old) with severe uncontrolled asthma were studied. They were treated with nebulized budesonide (1-4 mg day-1) and treated for at least 6 months. Height standard deviation scores (HtSDS) were measured before ("pre-measurements") immediately prior to commencing nebulized budesonide therapy (baseline) and after at least 6 months of therapy ("post-measurements"). The mean HtSDS score at pretreatment was -0.21 and at baseline had fallen further to -0.46. The mean HtSDS increased to -0.17 when the post-measurements were made (p = 0.035) after at least 6 months of nebulized budesonide therapy. Treatment with nebulized budesonide for longer than 6 months in very young children with severe asthma was not associated with reduced linear growth.

Caffeine antinociception: role of formalin concentration and adenosine A1 and A2 receptors

Caffeine produces antinociception in the formalin test at lower doses than in thermal threshold tests. In this study, we examined (a) the effect of formalin concentration on the action of caffeine, and (b) the relative involvement of adenosine A1 and A2 receptors in the action of caffeine. Formalin 1%, 2% and 5% produces a concentration-dependent increase in flinching behaviour in rats. At 5% formalin, the EC50 for caffeine in reducing phase 2 responses (16-60 min following formalin injection) is 40 mg/kg, but at 2%, this is reduced to 5 mg/kg. There is no further shift using 1% formalin. Caffeine has a more pronounced effect on phase 2A (16-36 min) than on phase 2, with significant effects being observed at lower doses. Both 8-cyclopentyltheophylline (A1 selective) and 3,7-dimethyl-1-propargylxanthine (A2 selective) produce a dose-related inhibition of 1.5% formalin flinching behaviours between 1-10 mg/kg. Both agents also produce locomotor stimulation over this dose range, but significant effects occur only at 10 mg/kg. These results indicate that antinociception by caffeine shows a high dependence on stimulus intensity. At 1-2% formalin, doses of caffeine that produce antinociception are now in the range that corresponds to normal human dietary and therapeutic intake levels. Both antinociception and locomotor stimulation appear to be dependent on activation of adenosine A1 receptors, as effects of 3,7-dimethyl-1-propargylxanthine are observed only at a dose which blocks adenosine A1 receptors in addition to A2 receptors.

Developments on the Internet: a practical guide for primary care physicians

Recent developments have made the Internet a helpful professional resource for primary care practitioners. The introduction of the World Wide Web has overcome many of the barriers that previously made it difficult to access useful information on the Internet. For teachers of primary care, the capability of combining graphic, sound, and video files is particularly exciting. User-friendly search strategies help users find needed information quickly. This article provides practical steps for accessing the Internet, introduces the concept of the World Wide Web, and provides a list of specific resources useful to primary care teachers, clinicians, and researchers.

Leukemia translocation gene, PLZF, is expressed with a speckled nuclear pattern in early hematopoietic progenitors

The PLZF gene was discovered by studying a rearrangement of the RAR alpha locus in a patient with acute promyelocytic leukemia and a t(11;17) chromosomal translocation. To understand further the potential role(s) of the PLZF gene product in hematopoiesis, we have examined its expression levels in a variety of murine tissues and in established cell lines that are representative of various stages of myeloid and lymphoid development. We show that murine PLZF(mPLZF) is expressed at the highest levels in undifferentiated, multipotential hematopoietic progenitor cells and that its expression declines as cells become more mature and committed to various hematopoietic lineages. Data obtained with established cell lines are corroborated by results showing the lack of human PLZF protein expression in mature peripheral blood mononuclear cells and high PLZF levels in the nuclei of CD34+ human bone marrow progenitor cells. Interestingly, unlike many transcription factors, PLZF protein in these cells possesses distinct punctate nuclear distribution, suggesting its compartmentalization in the nucleus. Taken together, our data suggest a role for PLZF protein in early hematopoiesis and the requirement of downregulation of its expression for proper differentiation of most hematopoietic lineages.

Interactions of descending serotonergic systems with other neurotransmitters in the modulation of nociception

The effects of 5-hydroxytryptamine (5-HT) and ligands selective for particular 5-HT receptor subtypes on the transmission of nociceptive information in the spinal cord are complex. In these studies, we have focused on their interactions with two endogenous mediators of pain suppression, noradrenaline (NA) and adenosine. Spinal antinociception by 5-HT is blocked by alpha-adrenoreceptor antagonists and depletion of endogenous NA by 6-hydroxydopamine, while it is potentiated by blockade of NA reuptake with desipramine. These observations provide evidence for a 5-HT receptor-mediated increase in the release of NA from the spinal cord. This action appears to be due to activation of a 5-HT1-like receptor as it is mimicked by some 5-HT1 receptor ligands (mCPP, TFMPP and 5-Me-O-DMT), but not by DOI (5-HT2) or 2-Me-5-HT (5-HT3). An additional component of 5-HT action is via release of adenosine. Antinociception by 5-HT is blocked by the adenosine receptor antagonist 8-phenyltheophylline, and 5-HT has been shown to release adenosine from the spinal cord in in vitro and in vivo paradigms. Methylxanthine-sensitive antinociception is seen with some 5-HT1 receptor ligands (CGS 12066B, mCPP), but not with others or with DOI or 2-Me-5-HT. Further characterization of the 5-HT receptor subtype involved in adenosine release will require the use of additional approaches.

Metallothionein expression in human breast cancer

Metallothioneins are ubiquitous low molecular weight proteins characterised by high cysteine content and affinity for binding heavy metals. Abnormal metallothionein function and expression have been implicated in various disease states, including neoplasia. The aim of this study was to investigate metallothionein expression in human breast carcinoma. Sections of routinely fixed and processed blocks of tumour from 100 consecutive cases of primary operable breast carcinoma were stained for metallothionein using a recently developed monoclonal antibody and a standard immunohistochemical technique. Expression was scored on the basis of microscopical assessment of percentage of tumour cells staining. One patient was lost to follow-up and excluded from the study. A significant association (P < 0.0001) was observed between metallothionein expression and tumour type, with low levels being observed in tumours of good prognostic type. There was also a significant association with local recurrence (P < 0.02) and a significant difference (P < 0.02) in both survival and disease-free interval between tumours showing low and high levels of expression, the latter indicating a poor prognosis. No relationship was observed with patient age, tumour size, lymph node stage, histological grade, vascular invasion, menopausal status or oestrogen receptor status. The assessment of metallothionein expression in human breast cancer appears to provide prognostic information and may have important implications for understanding its development.

Vascular emergencies: what's in season?

Seasonality in ischaemic coronary artery disease is well documented with a winter/summer variation the commonest pattern. The influence of seasonal variation on events in other vascular territories is less well documented. The incidence of ruptured abdominal aortic aneurysm and emergency lower-limb ischaemia was analysed on a monthly basis over a 5-year period. A total of 372 ruptured abdominal aortic aneurysms occurred with a peak incidence in spring and autumn; however, no seasonal pattern was seen in the rate of emergency admissions with lower-limb ischaemia (n = 606). The explanation for this seasonal pattern in ruptured aneurysms is unknown. The haemodynamic adjustments to changes in climate require further study.

Quality of life following infragenicular bypass and lower limb amputation

AIMS

To objectively assess the quality of life after femorodistal bypass and compare this to quality of life achieved following primary limb amputation.

DESIGN

Retrospective review.

SETTING

Leicester Royal Infirmary, U.K., 1988-1993.

METHODS

A self-assessment postal questionnaire containing scales measuring emotional disorder, social functioning and mobility was sent to 112 patients who had previously undergone femorodistal bypass (n = 86) or primary limb amputation (n = 26).

RESULTS

Further analysis demonstrated that a secondary procedure (PTA or graft revision) to maintain graft patency did not adversely affect quality of life. Additionally, patients undergoing secondary amputation after graft failure had an identical quality of life to those undergoing primary amputation.

CONCLUSIONS

These data illustrate that the quality of life after successful femorodistal bypass is higher than after primary or secondary amputation. To attain the maximum quality of life in patients with critical ischaemia, femorodistal bypass should be performed wherever feasible.

The changing workload of a surgical unit with a vascular interest

OBJECTIVES

To examine the changing relationship between general and vascular surgical workload on a vascular "firm", over a 6-year period.

DESIGN

Retrospective review.

SETTING

Leicester Royal Infirmary and Professorial Surgical Unit, U.K. 1987-1992.

METHOD

Analysis of audit of all surgical admissions. Relation of vascular surgery to general surgery.

RESULTS

There has been a slight decrease (5%) in the number of general surgical elective admissions. Overall, the number of general surgical admissions, both elective and emergency, show a slight increase of about 3%. In contrast the number of vascular admissions increased by 42%. Of the general surgical procedures carried out 75.9% were either minor or intermediate, whereas 92.5% of vascular procedures were coded as major or higher. There has been a three times increase in the number of carotid endarterectomies, a similar increase in the number of the femorodistal bypass grafts and a halving of the number of major amputations. There has also been a five times increase in the number of angioplasties carried out.

CONCLUSIONS

Our figures show the progressive, rapid increase in vascular surgical workload, compared to general surgery, and the need for the continued expansion of vascular surgery as a speciality.

Spinal supersensitivity to 5-HT1, 5-HT2 and 5-HT3 receptor agonists following 5,7-dihydroxytryptamine

The present study examined functional supersensitivity to 5-hydroxytryptamine (5-HT) and 5-HT ligands selective for 5-HT1, 5-HT2 and 5-HT3 receptors in two tests for nociception following the spinal administration of 5,7-dihydroxytryptamine (5,7-DHT). Intrathecal pretreatment with 5,7-DHT 30-100 micrograms (following desipramine) produced a selective depletion of spinal cord 5-HT levels of > 80% and augmented the antinociceptive action of 5-HT in the tail flick and hot plate tests. The tail flick test was the more sensitive test for expression of this action. Supersensitivity was observed with the 5-HT1 receptor ligands CGS 12066B (7-trifluoromethyl-4-(4-methyl-1-piperazinyl-pyrrolo[1,2-a] quinoxalinedimaleate), RU 24969 (5-methoxy-3-(1,2,4,6-tetrahydro-4-pyridinyl)1H indole succinate), TFMPP (m-trifluoromethylphenyl-piperazine HCl), mCPP (1-(3-chlorophenyl)piperazine dihydrochloride) and 5-Me-ODMT (5-methoxy-N,N-dimethyltryptamine hydrogen oxalate) but not with the 5-HT2 receptor ligand DOI ((+/-)-1-(4-iodo-2,5-dimethoxyphenyl)-2-aminopropane HCl) or the 5-HT3 receptor ligand 2-Me-5-HT (2-methyl-5-hydroxytryptamine maleate) in the tail flick test. In the hot plate test, supersensitivity was observed only with 5-Me-ODMT. Intrathecal pretreatment with fluoxetine, a 5-HT uptake inhibitor, potentiated the action of 5-HT but not any of the other 5-HT1 receptor ligands examined. These results indicate that supersensitivity occurs with 5-HT and 5-HT1 receptor ligands but not with 5-HT2 or 5-HT3 receptor ligands. Both the loss of uptake sites and receptor upregulation may contribute to enhanced activity of 5-HT, but for other ligands, only the latter mechanism appears to occur.

Common congenital heart defects. Long-term follow-up

Dramatic advances in the diagnosis and treatment of patients with congenital heart disease (CHD) have profoundly increased their survival rate. More than 500,000 patients in the United States with functionally significant congenital cardiac defects have reached adulthood. The focus of this article is to present an overview of the long-term surgical outcomes of the following common congenital heart defects: atrial septal defect, pulmonary stenosis, ventricular septal defect, coarctation of the aorta, aortic stenosis, tetralogy of Fallot, and transposition of the great arteries.

Tinnitus in pregnancy

The presence of tinnitus in pregnancy was investigated by a postal questionnaire survey. A group of pregnant women attending the ante-natal clinic and a control group of non-pregnant members of the nursing staff at the Royal United Hospital in Bath were studied. The prevalence of tinnitus in the pregnant and non-pregnant women was compared. Both groups were similar in age, previous noise exposure and the presence of ear disease or operations. Twenty-five per cent of the pregnant women reported tinnitus compared with 11% of the control group. Chi-square analysis of this data gives a value of chi 2 = 4.07, d.f. = 1, P < 0.05. The result of our survey shows that there is significantly increased prevalence of tinnitus in pregnant women compared with a similar non-pregnant control group. This association has not been previously reported.

Chronic critical leg ischaemia must be redefined

The Second European Consensus Document on Chronic Critical Leg Ischaemia defines critical limb ischaemia in non-diabetic patients as rest pain or tissue necrosis (ulceration or gangrene) with an ankle systolic pressure (ASP) of less than or equal to 50 mmHg, or a toe pressure of less than or equal to 30 mmHg. The aim of this study was to investigate whether this definition is able to predict the outcome of patients with severe lower limb ischaemia and thus to determine the relevance of the definition in clinical practice. We have analysed 148 severely ischaemic limbs in 133 non-diabetic patients who presented with rest pain, tissue necrosis or a combination of these symptoms. Fifty-one percent of these limbs fulfilled the current definition with an ASP < or = 50 mmHg; 49% had an ASP > 50 mmHg and were thus not defined as critically ischaemic according to the current definition. We have compared actuarial limb salvage and mortality rates in patients with an ASP < or = 50 mmHg to those patients with an ASP > 50 mmHg. The 1 year limb salvage and mortality rates for ischaemic limbs fulfilling the European Consensus Document criteria were 78.7 and 36.7% respectively, compared to rates of 73.9 and 17.3% in patients who were not defined as critically ischaemic under the current definition. There were no significant differences between 1 year limb salvage or mortality rates between the two patients groups (p = 0.843, 0.078, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Determination of B-cell clonality in paraffin-embedded lymph nodes using the polymerase chain reaction

Formalin-fixed, paraffin-embedded tissue from B-cell malignant lymphomas (26), reactive lymphadenopathies (8), non-B-cell malignancies (5), and atypical lymphoproliferative lesions (7) were analyzed for clonal immunoglobulin heavy chain gene rearrangement by the polymerase chain reaction (PCR), using consensus primers for the variable and joining regions of the gene. By employing a high-resolution gel electrophoresis technique, we were able to demonstrate one or two dominant bands, indicating a clonal population, in 15 of the 23 cases (65%) of B-cell lymphoma in which amplification occurred. Six of six reactive lymph nodes in which amplification occurred produced a multi-banded pattern indicative of a polyclonal population. This improved PCR technique allows a clearer distinction between clonal and polyclonal patterns than other previously proposed methods. It also works well in paraffin-embedded tissue and may therefore be a useful adjunct to the diagnostic armamentarium applied to archival material.

Barriers to adherence to preventive services reminder letters: the patient's perspective

BACKGROUND

Despite an emerging consensus as to which preventive services are appropriate, a minority of patients receive them. Although adherence to recommendations for some interventions has increased, research studies have shown that adherence rates can be further improved through a better understanding of patient attitudes and motivations regarding preventive services.

METHODS

Using components of the Patient Path Model, this study examined the response to patient reminder letters for cholesterol screening sent to 1077 adult patients between August and October 1990. The research strategy incorporated both quantitative and qualitative methods, including a telephone survey and focus group interviews of nonresponders to the reminder letter.

RESULTS

Three hundred seven patients were surveyed by telephone to ascertain their reasons for nonresponse. One hundred fifty-four (50.2%) did not recall receiving the reminder letter, 84 (27.4%) recalled receiving the letter but did not recall its content, and 69 (22.5%) recalled both receiving the letter and its content. No consistent reason for nonadherence emerged among the 69 nonresponders who recalled the reminder. Twenty-seven of the nonresponders who did not recall receiving the cholesterol reminder participated in the focus groups. The participants stressed the importance of distinguishing the reminder letter from a bill, conveying a personally relevant message, and addressing logistical barriers to preventive services.

CONCLUSIONS

Careful attention to the format and content of patient reminder letters is necessary to improve adherence to preventive services recommendations.

Use of whole cotton seed as a dietary supplement for grazing dairy cows

In a 2-part preliminary experiment, groups of 6 and 9 Holstein-Friesian cows in early t o mid lactation were unsupplemented or supplemented with either 3 kg cracked sorghum grain or 3 kg whole cotton seed on a base pasture of irrigated pangola grass for 12 weeks or oats for 12 weeks. The stocking rate was 5 cows/ha. Supplementation did not affect milk yield or composition. In a second experiment a group of 20 Holstein- Friesian cows in early to mid lactation grazed on a base pasture of subterranean clover at a stocking rate of 4 or 6 cows/ha a n d w e r e either unsupplemented or supplemented with 3 kg of whole cotton seed (WCS) over 12 weeks. Milk yield averaged 20.3 kg/cow.day and there were no significant effects on milk yield or composition. We suggest the lack of a significant milk yield response was due to a high substitution rate of WCS for pasture, associated with an oil content in the diet of 7.1 % of dry matter.

The prevalence of perilymphatic hypertension in subjects with tinnitus: a pilot study

This study investigated the prevalence of perilymphatic hypertension (raised perilymphatic pressure) in a population of subjects with tinnitus. A review of the literature showed how changes in perilymphatic pressure could affect tympanic membrane displacement measurements. This review also revealed that perilymphatic hypertension was more likely to occur in young females (less than 45 years) than in other subjects. An experiment was designed to test 32 subjects, who were divided into four groups according to their age and sex. These subjects underwent several routine audiological tests and were then tested with the tympanic membrane measurement system to determine the perilymphatic pressure of both ears. Statistical analysis of the experimental results showed that the young females had raised perilymphatic pressure. This was significantly higher than the perilymphatic pressure of the other test groups and of that of a normal population. The young females also exhibited other symptoms indicative of raised perilymphatic pressure. The raised pressure was thought to be due to an increase in fluid pressure which is more likely to occur in females due to variations in the levels of circulating hormones with menstrual irregularities, pregnancy and the menopause.

Noradrenergic mediation of spinal antinociception by 5-hydroxytryptamine: characterization of receptor subtypes

The present study examined the involvement of spinal noradrenergic mechanisms in spinal antinociception by the 5-hydroxy-tryptamine (5-HT) receptor-selective agonists CGS 12066B (5-HT1B; 7-trifluoromethyl-4(4-methyl-1-piperazinyl)-pyrrolo[1,2-a]quinoxaline), TFMPP (5-HT1C; M-trifluoromethylphenyl-piperazine) and DOI (5-HT2; 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane) using the rat hot plate test. Effects of alpha-adrenoreceptor antagonists (phentolamine, yohimbine), the adrenergic neurotoxin 6-hydroxydopamine, and the selective noradrenergic uptake blocker desipramine were determined. CGS 12066B, TFMPP and DOI produced dose-related antinociception. The antinociceptive effect of each agent was reduced by pretreatment with both phentolamine and yohimbine (15-60 micrograms). Pretreatment with 6-hydroxydopamine (100 micrograms, intrathecal) for 7-10 days, which reduced spinal cord levels of noradrenaline by 87%, inhibited the action of TFMPP (and 5-HT), but not CGS 12066B or DOI. Pretreatment with desipramine (25 mg/kg, systemic) potentiated the action of TFMPP but not CGS 12066B or DOI (or 2-methyl-5-HT). These results suggest that antinociception by TFMPP is dependent on release of endogenous noradrenaline from the spinal cord, while that produced by CGS 12066B and DOI is not. As TFMPP exhibits a close similarity to 5-HT in these experiments, the 5-HT receptor subtype being activated to induce noradrenaline release may either be a 5-HT1C or a 5-HT1S subtype. Other mechanisms account for the observed blockade of the action of CGS 12066B and DOI by alpha-adrenoreceptor antagonists.