Feasibility and compliance of automated measurement of quality of life in oncology practice

PURPOSE

Systematic quality-of-life (QOL) assessment may have value in oncology practice by increasing awareness of a wide range of issues, possibly increasing detection of psychologic morbidity, social problems, and changes in physical status, and improving care and its outcomes. However, logistic problems are substantial. Automated systems solve many of these problems. We field-tested the feasibility and compliance that can be achieved using a computer touchscreen system in two consecutive studies.

PATIENTS AND METHODS

In study 1, a prospective cohort of 272 patients was offered QOL assessment at each clinic appointment for 6 months. In study 2, all patients (N = 1,291) were offered QOL assessment as part of clinic routine during a 12-week period.

RESULTS

In study 1, 82% of patients agreed to take part, but over time, compliance was poor (median, 40%; mean, 43%) and deteriorated with longer follow-up. In study 2, the overall compliance was greatly increased (median, 100%; mean, 70%), and compliance was retained over multiple visits. In study 1, compliance was better in younger patients, males, and socially advantaged patients, but was not affected by the presence of depression or anxiety, or QOL. In the second study, building on experience in the first study, data collection and storage in the computer system was excellent, achieving 98% of collected data stored in one center. In general, patients were comfortable with the computers and the approach. Data collection on the wards was more difficult and less complete than in clinics, especially for patients undergoing acute admissions.

CONCLUSION

Feasibility with higher compliance was demonstrated in study 2, in which the data collection was integrated into routine care, and can be improved with further technical initiatives and education of staff.

Cervical node metastases in oropharyngeal squamous cell carcinoma: prospective analysis of prevalence and distribution

The treatment of cervical lymph node metastases is an important part of the management of oropharyngeal squamous cell cancer. Metastases are already clinically present in 61 per cent (+ or -2.6 per cent) of patients at presentation. Previous studies concerning the prevalence and distribution of neck node metastases in oropharyngeal carcinoma have been retrospective, and little or no information is available about the histopathological methods used. This study has prospectively analysed 85 neck dissection specimens in 72 consecutive patients with squamous cell carcinoma of the oropharynx, both with clinically N(0) and N+ve necks, to identify the prevalence and distribution of cervical metastases. We have used a technique to separate the neck dissection into nodal levels per-operatively, and then embedded the entire specimen for histological examination to avoid missing metastatic disease in small lymph nodes (<3mm diameter).

Effect of conformational aspects on the movement of the equine back

The relationship between structure and function is important in the judgement of the horse. Twenty sound riding horses walked and trotted on a treadmill. The movement of the backs of each of the horses was measured using a commercially available movement analysis system. Morphometric, spatiotemporal and kinematic information were correlated to investigate the effect of conformation on movement. Taller and heavier horses seem to have longer thoracic and lumbar backs, and are wider at the pelvis. Horses with longer strides extended and flexed their backs in the caudal saddle region to a greater extent at the walk, but not the trot. Horses with greater angle of L5 tend to extend and flex this region of the back more. At the walk and trot, a long thoracic back results in greater lumbar lateral bending. A negative relationship was found between the curvature of mid-thoracic back and the amount of lateral bending of L1 and L3 and axial rotation of the pelvis at the trot. There are clear relationships between back conformation and movement that may be important to the orthopaedic health of the horse. Further understanding of the relationships between conformation, movement and injury may provide an objective basis for the evaluation of future performance and soundness.

Influence of draw reins on ground reaction forces at the trot

According to riding texts, draw reins are supposed to support increased collection. This has not been measured objectively. Therefore, the objective of this study was to determine whether a horse ridden with draw reins would relatively increase weightbearing of the hindquarters while worked with the draw reins compared to a normal rein. Ground reaction forces were measured in 8 horses at the slow trot over a force plate in 3 different experimental set-ups: 1) riding with only a draw rein (DR); 2) riding with the combination of a normal and a draw rein (NR-DR) and 3) riding with a normal rein (NR). Horses ridden with NR-DR showed significant higher vertical impulse in the hindlimb compared to riding both with only DR and only NR. Several significant differences were also seen in the horizontal force. It is concluded that draw reins, when used correctly, together with a normal rein, achieve the desired result of shifting the weight of the horse caudally. This was not the case when the draw rein was used alone. It is important that trainers, as well as veterinarians, recommending draw reins in a rehabilitation programme, know about these possible effects.

Nietzsche and the dilemma of suffering

In this paper, we attempt to view a long-held assumption in nursing as mistaken. That is, that patient suffering is something to be overcome. Utilizing Nietzsche's statements on Amor Fati, we carefully examine the cultural assumptions behind our denigration of suffering, look at specific nursing examples of this situation, and attempt the beginnings of a discourse on what it would take for nurses to overcome their own predetermined views of suffering in order to better help their patients "own" their own suffering.

Comparison of survival, palliation, and quality of life with three chemotherapy regimens in metastatic colorectal cancer: a multicentre randomised trial

BACKGROUND

This randomised trial compared three chemotherapy regimens in the first-line treatment of advanced colorectal cancer, in terms of their effect on overall and progression-free survival; other endpoints included toxicity, symptom palliation, and quality of life.

METHODS

905 patients were randomly assigned the de Gramont regimen (n=303; folinic acid 200 mg/m(2), fluorouracil bolus 400 mg/m(2), and infusion 600 mg/m(2) on days 1 and 2, repeated every 14 days), the Lokich regimen (n=301; protracted venous infusion of fluorouracil 300 mg/m(2) daily), or raltitrexed (n=301; 3 mg/m(2) intravenously every 21 days). Analyses were by intention to treat.

FINDINGS

Median follow-up of survivors was 67 weeks. For the de Gramont, Lokich, and raltitrexed groups, respectively, median survival was 294, 302, and 266 days. The hazard ratios for overall survival were 0.88 (95% CI 0.70-1.12, p=0.17) for de Gramont versus Lokich, and 0.99 (0.79-1.25, p=0.94) for de Gramont versus raltitrexed. An increase in treatment-related deaths was seen on raltitrexed (de Gramont one, Lokich two, raltitrexed 18) due to combined gastrointestinal and haematological toxicity. Patients' assessment of quality of life showed that raltitrexed was inferior to the fluorouracil-based regimens, especially in terms of palliation and functioning.

INTERPRETATION

The deGramont and Lokich regimens were similar in terms of survival, quality of life, and response rates. The Lokich regimen was associated with more central line complications and hand-foot syndrome. Raltitrexed showed similar response rates and overall survival to the de Gramont regimen and was easier to administer, but resulted in greater toxicity and inferior quality of life.

Repeatability of back kinematics in horses during treadmill locomotion

We tested the hypothesis that repeatability of a standardised protocol for quantifying back kinematics is sufficiently high not to prevent its use in the clinical evaluation of horses with back problems. We investigated the extent to which differences between laboratories may affect the results when a standardised protocol is used. As a clinical tool, movement analysis techniques are helpful for the objective and quantitative assessment of kinematics. Knowledge about the repeatability of the kinematic data is very important. The present study investigates the repeatability of back kinematics in 10 sound horses over 5 successive days and in 2 laboratories (5 horses at each location). Measurements were performed on the treadmill during the walk and the trot. The between-stride, between-day and between-horse repeatability were determined. A high degree of between-stride and between-day repeatability was observed in the spatiotemporal parameters and in the time-angle diagrams of thoracic and lumbar vertebrae, the sacrum and the hindlimb during both the walk and trot. Much more variability was found between horses, with the highest degree of dissimilarity in the lateral bending rotation of the L1 vertebra. For range of motion values, the between-day coefficient of variability was <14% and the between-horse coefficient of variability was up to 4 times higher. Small differences were found in range of motion values between the 2 laboratories. It is concluded that an analysis of back kinematics in the horse can provide highly repeatable data, warranting clinical use.

Long-term implantation of preadipocyte-seeded PLGA scaffolds

Studies were performed in a long-term effort to develop clinically translatable, tissue engineered adipose constructs for reconstructive, correctional, and cosmetic indications. Rat preadipocytes were harvested, isolated, expanded ex vivo, and seeded within PLGA scaffolds. Preadipocyte-seeded and acellular (control) scaffolds were implanted for 1-12 months. Explanted scaffolds were stained with osmium tetroxide, processed, and counterstained using H&E. Quantitative histomorphometric analysis was performed on all tissue sections to determine the amount of adipose tissue formed. Analyses revealed maximum adipose formation at 2 months, followed by a decrease at 3 months, and complete absence of adipose and PLGA at 5-12 months. These results extend a previous short-term study (Tissue Engineering 1999;5:134) and demonstrate that adipose tissue can be formed in vivo using tissue engineering strategies. However, the long-term maintenance of adipose tissue remains elusive.

Pathophysiologic and therapeutic importance of tissue ACE: a consensus report

Angiotensin-converting enzyme (ACE) activation and the de novo production of angiotensin II contribute to cardiovascular disease through direct pathological tissue effects, including vascular remodeling and inflammation, as well as indirect action on nitric oxide bioavailability and its consequences. The endothelium plays a pivotal role in both vascular function and structure; thus, the predominant localization of ACE to the endothelium has implications for the pathobiology of vascular disease, such as coronary artery disease. Numerous experimental studies and clinical trials support the emerging realization that tissue ACE is a vital therapeutic target, and that its inhibition may restore endothelial function or prevent endothelial dysfunction. These effects exceed those attributable to blood pressure reduction alone; hence, ACE inhibitors may exert an important part of their effects through direct tissue action. Pharmacologic studies show that while ACE inhibitors may differ according to their binding affinity for tissue ACE the clinical significance remains to be determined.

Design of the Omapatrilat in Persons with Enhanced Risk of Atherosclerotic events (OPERA) trial

The Omapatrilat in Persons with Enhanced Risk of Atherosclerotic events (OPERA) trial is a large clinical trial of omapatrilat, a vasopeptidase inhibitor, in patients with stage 1 isolated systolic hypertension (ISH). OPERA is the first study to examine whether effective antihypertensive treatment can provide survival and clinical end point benefits in older persons with this common condition. This 5-year multinational, randomized, double-blind, parallel-group, placebo-controlled, forced-titration study will be conducted in approximately 12,600 subjects randomized by approximately 1100 study centers worldwide over a recruitment period of approximately 2 years. The primary objective of OPERA is to determine whether treatment with once-daily omapatrilat (target dose 40 mg) will reduce cardiovascular (CV) morbidity and mortality in older (> or = 65 years) men and women with enhanced risk for atherosclerotic events due to stage 1 ISH plus other risk factors for which currently there is no evidence-based requirement for treatment. Blood pressure inclusion criteria are systolic blood pressure (SBP) 140 to 159 mm Hg (SBP 125 to 139 mm Hg in diabetic individuals) and diastolic blood pressure (DBP) <90 mm Hg. The primary end point is defined as the composite of fatal/nonfatal stroke, fatal/nonfatal myocardial infarction, fatal/nonfatal heart failure, and other CV mortality. Secondary end points include the individual components of the primary end point, CV mortality, and major cardiovascular end points, as well as effects on cognitive function and initiation of treatment for diabetes. Additional analyses will be conducted in men and women, in diabetic patients, in different risk classes and according to prior evidence of vascular disease.

Does smoking increase relapse rates in Graves' disease?

We wondered whether the relapse rate of Graves' hyperthyroidism was increased amongst patients who smoked. To this end, a retrospective analysis of clinical and laboratory data of consecutive patients with Graves' disease was carried out. All patients were treated with thionamide anti-thyroid drugs (ATD) for at least one year and remission was defined as continued and biochemical euthyroidism, at least 6 months after discontinuing ATD. The study comprised 221 subjects with Graves' disease from a hospital-based population over 9 years. We took the following variables into account when assessing contribution to disease relapse: Goiter, Thyroid Associated Ophthalmopathy (TAO), and Time to euthyroidism after starting ATD and interaction between smoking and sex. Smoking had a marginally significant (p=0.081) deleterious effect on the likelihood of remission after ATD treatment for Graves' disease. The effect of smoking was, however, highly significant in males and indeed the deleterious effect on remissions may be restricted to males (odds ratio, 11.1; 95% confidence interval, 1.25 to 98.5). The presence of goiter (odds ratio, 3.8; 95% confidence interval, 2.05 to 7.1) and TAO (odds ratio, 1.8; 95% confidence interval, 0.993 to 3.18) forecasted lower chances of achieving remission. The shorter the time a patient became euthyroid after starting ATD the more likely his disease was to remit. We conclude that cigarette smoking increases the likelihood of Graves' disease recurrence in males treated with anti-thyroid drugs. Thus, smoking appears to be an important risk factor in the pathogenesis and outcome of Graves' disease patients at least in subsets of patients.

Comparison of the RNA-amplification based methods RT-PCR and NASBA for the detection of circulating tumour cells

Increasingly, reverse transcriptase polymerase chain reaction (RT-PCR) is used to detect clinically significant tumour cells in blood or bone marrow. This may result in a redefinition of disease-free and clinical relapse. However, its clinical utility may be limited by lack of automation or reproducibility. Recent studies have suggested nucleic acid sequence-based amplification of target RNA may be more robust. In this study, nucleic acid sequence-based amplification was established to detect melanoma, colorectal and prostate cancer cells. Nucleic acid sequence-based amplification and RT-PCR both successfully amplified target RNA in peripheral blood samples from patients with melanoma and colorectal cancer, but only RT-PCR detected PSA in blood samples from patients with prostate cancer. There was relatively good agreement between sample replicates analyzed by RT-PCR (Kappa values of one for tyrosinase, 0.67 for CK-20 and one for PSA), but less agreement when analyzed by nucleic acid sequence-based amplification. This may limit the routine use of NASBA for the detection of clinically significant disease. In summary, RT-PCR appears at present to be the most reliable and reproducible method for the detection of low-level disease in cancer patients, although prospective studies are warranted to assess the clinical utility of different molecular diagnostic methods.

Underestimation of the importance of homocysteine as a risk factor for cardiovascular disease in epidemiological studies

BACKGROUND

In epidemiological studies, within-person variability in plasma total homocysteine (tHcy) measurements may dilute the association of 'usual' levels of tHcy with risk of cardiovascular disease, referred to as 'regression dilution'. The aim of this report was to estimate the magnitude of regression dilution after varying intervals of follow-up.

METHODS

Regression dilution ratios (RDR) for tHcy were calculated using replicate tHcy measurements obtained after 3, 6 and 8 years from the Rotterdam, Hordaland and Framingham studies, respectively, and after 3, 6, 9 and 12 years from the United Kingdom Prospective Study of type 2 Diabetes Mellitus (UKPDS).

RESULTS

The RDR for tHcy decreased with increasing interval in the three population-based studies and in the UKPDS. Moreover, the rate of decline of the RDR in the population-based studies was similar to that obtained in the UKPDS. Using linear regression analysis for the population-based studies, these results suggest an RDR of 0.83 at 2 years, 0.71 at 6 years and 0.53 at 12 years.

CONCLUSIONS

These results have important implications for the interpretation of prospective studies of tHcy and cardiovascular disease. Failure to correct for increasing regression dilution using lower RDRs for longer follow-up may underestimate the relative risks of cardiovascular disease associated with tHcy by about one-fifth after 2 years and one-half after 10 years.

The relevance of tissue angiotensin-converting enzyme: manifestations in mechanistic and endpoint data

Angiotensin-converting enzyme (ACE) is primarily localized (>90%) in various tissues and organs, most notably on the endothelium but also within parenchyma and inflammatory cells. Tissue ACE is now recognized as a key factor in cardiovascular and renal diseases. Endothelial dysfunction, in response to a number of risk factors or injury such as hypertension, diabetes mellitus, hypercholesteremia, and cigarette smoking, disrupts the balance of vasodilation and vasoconstriction, vascular smooth muscle cell growth, the inflammatory and oxidative state of the vessel wall, and is associated with activation of tissue ACE. Pathologic activation of local ACE can have deleterious effects on the heart, vasculature, and the kidneys. The imbalance resulting from increased local formation of angiotensin II and increased bradykinin degradation favors cardiovascular disease. Indeed, ACE inhibitors effectively reduce high blood pressure and exert cardio- and renoprotective actions. Recent evidence suggests that a principal target of ACE inhibitor action is at the tissue sites. Pharmacokinetic properties of various ACE inhibitors indicate that there are differences in their binding characteristics for tissue ACE. Clinical studies comparing the effects of antihypertensives (especially ACE inhibitors) on endothelial function suggest differences. More comparative experimental and clinical studies should address the significance of these drug differences and their impact on clinical events.

Identification of genes involved in the host response to neurovirulent alphavirus infection

Single-amino-acid mutations in Sindbis virus proteins can convert clinically silent encephalitis into uniformly lethal disease. However, little is known about the host gene response during avirulent and virulent central nervous system (CNS) infections. To identify candidate host genes that modulate alphavirus neurovirulence, we utilized GeneChip Expression analysis to compare CNS gene expression in mice infected with two strains of Sindbis virus that differ by one amino acid in the E2 envelope glycoprotein. Infection with Sindbis virus, dsTE12H (E2-55 HIS), resulted in 100% mortality in 10-day-old mice, whereas no disease was observed in mice infected with dsTE12Q (E2-55 GLN). dsTE12H, compared with dsTE12Q, replicated to higher titers in mouse brain and induced more CNS apoptosis. Infection with the neurovirulent dsTE12H strain was associated with both a greater number of host genes with increased expression and greater changes in levels of host gene expression than was infection with the nonvirulent dsTE12Q strain. In particular, dsTE12H infection resulted in greater increases in the levels of mRNAs encoding chemokines, proteins involved in antigen presentation and protein degradation, complement proteins, interferon-regulated proteins, and mitochondrial proteins. At least some of these increases may be beneficial for the host, as evidenced by the demonstration that enforced expression of the antiapoptotic mitochondrial protein peripheral benzodiazepine receptor (PBR) protects neonatal mice against lethal Sindbis virus infection. Thus, our findings identify specific host genes that may play a role in the host protective or pathologic response to neurovirulent Sindbis virus infection.

Neurobehavioral phenotype in carriers of the fragile X premutation

There have been contradictory findings in the fragile X (fraX) literature about possible neurocognitive and psychological symptoms due to the fraX premutation (pM). The purpose of the present study was to investigate the relationship between CGG repeat length and neurobehavioral functioning in carriers of the fraX pM. Eighty-five female carriers of the pM with allele sizes ranging from 59-166 were administered a comprehensive IQ test (WAIS-III) and completed a questionnaire designed to measure psychopathology (Symptom Checklist (SCL)-90-R). No relationship between allele size and cognition was identified. A significant negative relationship between allele size and age was found, as well as a positive relationship between allele size and depression. Follow-up analyses separating small and large allele sizes (below and above 100 CGG repeats) indicated that individuals with larger allele sizes scored significantly higher on the Interpersonal Sensitivity and Depression subscales of the SCL-90-R. Despite the limitation of few individuals with high CGG repeat lengths, our findings suggest that females with larger premutated alleles (> or = 100 repeats) display some clinical manifestations of fraX syndrome.

Multiple endocrine neoplasia type 1Burin from Mauritius: a novel MEN1 mutation

We describe a kindred from Mauritius with an incomplete variant of multiple endocrine neoplasia type 1 (MEN 1Burin). In this family the syndrome is related to a novel MEN 1 gene mutation (deletion of A) at nucleotide 1021 of codon 304 resulting in frame shift and downstream protein truncation at codon 320. Compared to mainstream MEN 1, MEN 1Burin is characterized by a high prevalence of prolactin-secreting pituitary adenomas, late-onset of hyperparathyroidism and rare pancreatic involvement. The family described represents the fifth in the literature with the MEN 1 Burin phenotype; 2 out of the other 4 were related to R460X, Y312X respectively and no mutation within the coding sequence of MEN 1 was found in the other 2. Thus, similar to the classic syndrome, MEN 1Burin phenotype shows poor correlation to MEN 1 genotype.

Families of children with attention-deficit/hyperactivity disorder: review and recommendations for future research

This review integrates and critically evaluates what is known about family characteristics associated with childhood Attention-Deficit/Hyperactivity Disorder (ADHD). Evidence suggests that the presence of ADHD in children is associated to varying degrees with disturbances in family and marital functioning, disrupted parent-child relationships, specific patterns of parental cognitions about child behavior and reduced parenting self-efficacy, and increased levels of parenting stress and parental psychopathology, particularly when ADHD is comorbid with conduct problems. However, the review reveals that little is known about the developmental mechanisms that underlie these associations, or the pathways through which child and family characteristics transact to exert their influences over time. In addition, the influence of factors such as gender, culture, and ADHD subtype on the association between ADHD and family factors remains largely unknown. We conclude with recommendations regarding the necessity for research that will inform a developmental psychopathology perspective of ADHD.

Joint moments in the distal forelimbs of jumping horses during landing

Tendon injuries are an important problem in athletic horses and are probably caused by excessive loading of the tendons during demanding activities. As a first step towards understanding these injuries, the tendon loading was quantified during jump landings. Kinematics and ground reaction forces were collected from the leading and trailing forelimbs of 6 experienced jumping horses. Joint moments were calculated using inverse dynamic analysis. It was found that the variation of movement and loading patterns was small, both within and between horses. The peak flexor joint moments in the coffin and fetlock joints were larger in the trailing limb (-0.62 and -2.44 Nm/kg bwt, respectively) than in the leading limb (-0.44 and -1.93 Nm/kg bwt, respectively) and exceeded literature values for trot by 82 and 45%. Additionally, there was an extensor coffin joint moment in the first half of the stance phase of the leading limb (peak value 0.26+/-0.18 Nm/kg bwt). From these results, it was concluded that the loading of the flexor tendons during landing was higher in the trailing than in the leading limb and that there was an unexpected loading of the extensor tendon in the leading limb.

Professional perceptions of the benefits of orthodontic treatment

The aim of this study was to assess general dental practitioners' and orthodontists' perceptions of the benefits of orthodontic treatment. A specially designed questionnaire was sent to a random sample of 150 general dental practitioners (GDPs) and all orthodontists in Northern Ireland (excluding hospital practitioners) with a postgraduate qualification (n = 29). There was a 93 per cent response rate by the general dental practitioners and all but one specialist practitioner returned the questionnaire. The questionnaire comprised 14 visual analogue scales (VAS) whereby participants were asked to rate the importance of various possible dental health and psychosocial benefits of orthodontic treatment. In addition to the VAS, the influence of dentist variables such as number of years since qualification, orthodontic cases completed, referral rates and attendance at postgraduate lectures were examined. When ratings on the 14 dental health and psychosocial scales were examined overall, GDPs rated an improvement in self-esteem while orthodontists considered an improvement in physical attractiveness as the most important benefit of orthodontic treatment. Even though psychosocial variables received the highest ratings, examination of the mean ratings (and 95 per cent confidence intervals) revealed that some dental health factors were also rated highly by both groups. While the results do indicate an encouraging awareness of the psychosocial benefits of orthodontic treatment, they also suggest that both GDPs and orthodontists have an unrealistic expectation of the dental health gain likely to result from orthodontic treatment.

Characterization of the genomic Xist locus in rodents reveals conservation of overall gene structure and tandem repeats but rapid evolution of unique sequence

The Xist locus plays a central role in the regulation of X chromosome inactivation in mammals, although its exact mode of action remains to be elucidated. Evolutionary studies are important in identifying conserved genomic regions and defining their possible function. Here we report cloning, sequence analysis, and detailed characterization of the Xist gene from four closely related species of common vole (field mouse), Microtus arvalis. Our analysis reveals that there is overall conservation of Xist gene structure both between different vole species and relative to mouse and human Xist/XIST. Within transcribed sequence, there is significant conservation over five short regions of unique sequence and also over Xist-specific tandem repeats. The majority of unique sequences, however, are evolving at an unexpectedly high rate. This is also evident from analysis of flanking sequences, which reveals a very high rate of rearrangement and invasion of dispersed repeats. We discuss these results in the context of Xist gene function and evolution.

Altered intracellular localization of fibroblast growth factor receptor 3 in human breast cancer

Immunohistochemical staining of human breast tissues, using an antibody against fibroblast growth factor receptor 3 [FGFR-3], showed differences in cellular distribution. Both malignant and non-malignant epithelial cells contained FGFR-3 immunoreactivity, but myoepithelial cells and stroma were negative. The staining pattern in malignant epithelial cells was predominantly nuclear, whereas epithelial cells in normal breast tissue showed both cytoplasmic and nuclear elements. Reverse transcription-polymerase chain reaction (RT-PCR) revealed two isoforms of FGFR-3 corresponding to the FGFR-3-IIIb variant and a previously described exon-deleted nuclear form of FGFR-3, which were present in both malignant and non-malignant epithelial cells. The higher level of nuclear staining and loss of cytoplasmic staining seen in malignant epithelial cells did not correspond to an increase in expression of the exon-deleted form of FGFR-3, nor to any detectable activating point mutations. Since receptor activation can result in its movement to a perinuclear localization, an alternative explanation for the redistribution of FGFR-3-IIIb could be different degrees of activation by a ligand (FGF1 or FGF9). No FGF9 was detected by immunohistochemistry in breast tissues. FGF1, however, is present in the majority of breast cancers and a different tissue distribution of FGF1 was found in breast tissues, showing predominantly nuclear, or a mix of nuclear and cytoplasmic FGFR-3. The difference in FGFR-3 staining patterns may implicate this ligand-receptor pair in breast cancer.

Basic three-dimensional kinematics of the vertebral column of horses trotting on a treadmill

OBJECTIVE

To determine movements of the vertebral column of horses during normal locomotion.

ANIMALS

5 young Dutch Warmblood horses that did not have signs of back problems or lameness.

PROCEDURE

Kinematics of 8 vertebrae (T6, T10, T13, T17, L1, L3, L5, and S3) and both tuber coxae were determined, using bone-fixated markers. Measurements were recorded when the horses were trotting on a treadmill at a constant speed of 4.0 m/s.

RESULTS

Flexion-extension and axial rotation were characterized by a double sinusoidal pattern of motion during 1 stride cycle, whereas lateral bending was characterized by 1 peak and 1 trough. Ranges of motion for all vertebrae were: flexion-extension, 2.8 degrees to 4.9 degrees; lateral bending, 1.9 degrees to 3.6 degrees; axial rotation, 4.6 to 5.8 degrees, except for T10 and T13, where the amount of axial rotation decreased to 3.1 degrees and 3.3 degrees, respectively.

CONCLUSION AND CLINICAL RELEVANCE

During locomotion, 3 types of rotations are evident in the thoracolumbar vertebrae. Regional differences are observed in the shape and timing of the rotations. These differences are related to actions of the limbs. The method described here for direct measurement of vertebral column motion provides insights into the complex movements of the thoracolumbar portion of the vertebral column in trotting horses. Information on normal kinematics is a prerequisite for a better understanding of abnormal function of the vertebral column in horses.

Commercialism in classrooms

Opinions expressed in commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees. Commentaries are not peer-reviewed.

In vivo and in vitro heel expansion in relation to shoeing and frog pressure

The objective of this study was to validate a simple method to measure the mediolateral expansion of the heels and to apply this method in an in vivo experiment. It was also the aim to quantify the mediolateral expansion in different areas of the heel using an in vitro model. In the in vitro study, 5 right and 5 left distal forelimb specimens from 5 Standardbreds were mounted vertically in a custom-made compressive test machine. The heel expansion was measured using optical kinematic analysis and a potentiometer system. Specimens were tested unshod, with frog pressure and with the weightbearing rim raised. In the in vivo study, a potentiometer system was fitted to the left forelimb of 5 Standardbred trotters. Measurements were performed with the horses at hand, in walk and in trot. They were tested unshod, shod with a standard 8 mm iron shoe and finally with a shoe combined with an inflatable hoof-cushion. The results showed a good correlation between the 2 measurement systems (r = 0.98). This study describes the effect of different frog pressures on heel movement. Increased pressure on the frog and the sole increased heel expansion, but some heel expansion still occurred when the frog and sole were unsupported. The study supports, therefore, both the depression and the pressure theory. The significance of these results is the manipulation of heel movement as affected by farrier techniques and its possible relationship to health of the hoof. Further studies are needed to apply this knowledge correctly to farrier practice.

Forelimb tendon loading during jump landings and the influence of fence height

Lameness in athletic horses is often caused by forelimb tendon injuries, especially in the interosseus tendon (TI) and superficial digital flexor tendon (SDF), but also in the accessory ligament (AL) of the deep digital flexor tendon (DDF). In an attempt to explain the aetiology of these injuries, the present study investigated the loading of the tendons during landing after a jump. In jumping horses, the highest forces can be expected in the trailing limb during landing. Therefore, landing kinematics and ground reaction forces of the trailing forelimb were measured from 6 horses jumping single fences with low to medium heights of 0.80, 1.00 and 1.20 m. The tendon forces were calculated using inverse dynamics and an in vitro model of the lower forelimb. Calculated peak forces in the TI, SDF and DDF + AL during landing were 15.8, 13.9 and 11.7 kN respectively. The relative loading of the tendons (landing forces compared with failure forces determined in a separate study) increased from DDF to TI to SDF and was very high in SDF. This explains the low injury incidence of the DDF and the high injury incidence of the SDF. Fence height substantially influenced SDF forces, whereas it hardly influenced TI forces and did not influence AL strain. Reduction of fence height might therefore limit the risks for SDF injuries, but not for TI and AL injuries.

In vivo transmission of impact shock waves in the distal forelimb of the horse

There is a high prevalence of lameness among Standardbred trotters, most commonly caused by noninfectious joint diseases, mainly related to training and competition. In this context, impact-related shock waves transmitted through the skeleton and joints have been proposed to be one important factor in the development of osteoarthritis. The aim of the present study was to investigate the characteristic pattern of the events immediately following first contact, with a focus on the in vivo transmission of impact shock waves in the distal forelimb. Two horses were trotted by hand over a force plate. Recordings of 3-D kinematics of the distal forelimb were carried out by use of a 240 Hz video system. Tri-axial accelerometer data were collected from a bone-mounted accelerometer on the midlateral side of the third metacarpal bone (McIII) and from another accelerometer attached to the lateral side of the hoof. Force plate and accelerometer data were sampled at 4.8 kHz using a 16-bit A/D-converter, synchronised with the kinematic data. The results indicate that the time lapse of the horizontal retardation of the hoof is an important factor in the attenuation of the impact. A shorter period of hoof braking showed higher amplitudes in the longitudinal retardation of McIII and a more rapid oscillation. This makes all parameters that affect the horizontal hoof braking potentially important to the orthopaedic health of the horse.

Three-dimensional kinematics of the equine spine during canter

Most research on equine kinematics has previously been performed in the walking and/or trotting animal. This is also true for the few studies on the kinematics of the equine back. These studies have, for the major part, focused on the flexion-extension movement in the sagittal plane. However, vertebrae can rotate in 3 dimensions. This study was designed to determine all 3 rotations in various segments of the vertebral column of a cantering horse. Five Dutch Warmblood horses were measured during treadmill canter (7.3 m/s). Steinmann pins were inserted into the dorsal spinous processes of 8 thoracic (T), lumbar (L) and sacral (S) vertebrae and into both tubera coxae. A set of 4 markers was rigidly attached to each pin. The marker data were used to calculate a rotation matrix that was subsequently decomposed into 3 orthogonal rotations (flexion/extension [FE]; lateral bending [LB] and axial rotation [AR]). For the 3 rotations the variability between the horses was low for FE, slightly larger for AR and largest for LB. The maximal range of motion (mean +/- s.d.) for FE, LB and AR was 15.8 +/- 1.3 degrees, 5.2 +/- 0.7 degrees and 7.8 +/- 1.2 degrees, respectively. With respect to relative angles, the largest FE motion was found between L5 and S3 with values for the range of motion up to 8.6 degrees. Simultaneous rotation of successive vertebrae was observed particularly during the single support and suspension phases in the stride cycle, which increases spinal stability. For all rotations, a close correlation was observed between the timing of the vertebral rotations and the pro- and retraction of the limbs.

Primary non-random X inactivation associated with disruption of Xist promoter regulation

In this report we demonstrate primary non-random X chromosome inactivation following targeted mutagenesis of a region immediately upstream of XIST promoter P(1). In heterozygous animals there is a preferential inactivation of the targeted X chromosome in 80--90% of cells. The phenotype correlates with inappropriate activation of XIST in a proportion of the mutant XY embryonic stem cells. Strand-specific analysis revealed increased sense transcription initiating upstream of XIST promoter P(1). There was, however, no discernible effect on transcription from the antisense Tsix gene. We demonstrate that the in vitro and in vivo phenotypes are specifically attributable to the presence of a PGKneo cassette at the targeted locus. These findings are discussed in the context of understanding mechanisms of XIST gene regulation in X inactivation.

Parental and child cognitions in the context of the family

Parent and child family-related cognitions are reviewed with respect to (a) their origins, (b) their linkage to affect and behavior, (c) their transmission and perpetuation, (d) their alteration on the basis of first-hand experience, and (e) their collaborative negotiation and renegotiation. A distinction is offered between the functioning of implicit, relatively unaware, schematic cognitions and relatively aware, explicit, event-dependent cognitions. Consideration is also given to the differential content (or topics) of cognitions. As a positive outcome of recent research, many new insights have emerged with respect to the linkage of family members' cognitions and their individual and shared patterns of behavior. However, several limitations remain, including too little consideration of the shared influences of parents' and children's cognitions and the changes in these cognitions over time. As a growth area, there is emerging interest in the application of our knowledge of cognitions to the clinical context in programs designed to remediate and prevent family problems.

Effects of medication, behavioral, and combined treatments on parents' and children's attributions for the behavior of children with attention-deficit hyperactivity disorder

Seventy-four mothers and 41 fathers and their 6 to 13 year old sons with attention-deficit hyperactivity disorder (ADHD) watched videos of child ADHD symptoms, compliance, and noncompliance. Participants were told either that the child was receiving medication, behavioral treatment, a combination of the two, or was not receiving treatment and were asked to rate the cause of the behavior. Parents attributed less control but greater stability to positive child behaviors when the child was receiving medication. However, for negative behaviors, medication increased attributions of control but diminished stability. With behavior management. compliance was seen as more external and stable and noncompliance as more controllable but less stable. For all treatments, boys reported increased control over ADHD symptoms and noncompliance. The implications of these treatment-related attributions for parenting and children's self-perceptions are discussed.

Renormalized expression for the turbulent energy dissipation rate

Conditional elimination of degrees of freedom is shown to lead to an exact expression for the rate of turbulent energy dissipation in terms of a renormalized viscosity and a correction. The correction is neglected on the basis of a previous hypothesis [W. D. McComb and C. Johnston, J. Phys. A 33, L15 (2000)] that there is a range of parameters for which a quasistochastic estimate is a good approximation to the exact conditional average. This hypothesis was tested by a perturbative calculation to second order in the local Reynolds number, and the Kolmogorov prefactor (taken as a measure of the renormalized dissipation rate) was found to reach a fixed point which was insensitive to initial values of the kinematic viscosity and to values of the spatial rescaling factor h in the range 0.4< or =h< or =0.8.

HLA class I, II & III genes in confirmed late-onset Alzheimer's disease

We first examined all the then known alleles (1997) at the HLA-A, B, Bw, C, DRB1, 3, 4 and 5, and DQB1 loci in 55 late-onset (>65y) AD cases and 73 elderly controls from Oxford. We found an association of HLA-B7 with late-onset AD (odds ratio = 3.1, corrected P = 0.04) that was limited to apolipoprotein E epsilon4-negative subjects (odds ratio = 5.1, corrected P = 0.005). We then studied linkages with Class III genes and, finally, we sought to replicate our HLA-B7 result in cohorts from Montreal and Nottingham. Altogether, we used 299 histopathologically confirmed cases of late-onset AD and 175 controls. Our initial, clear finding was not replicated in Montreal and Nottingham, however. We also failed to support any other previously reported association of AD with an HLA gene. Though we cannot exclude distinct linkages in different cohorts as an explanation of the conflicting results of HLA/AD studies, we conclude that there is no compelling evidence of a strong, direct association between late-onset AD and any HLA Class I or II allele.

Structure and promoter activity of the mouse CDC25A gene

CDC25A is a member of a group of highly related, dual-specificity phosphatases that promote cell cycle phase transitions by regulating the activity of cyclin-dependent kinases. Here we report the cloning and genomic sequence of 21,067 nucleotides encompassing the mouse CDC25A gene. The coding sequence is expressed from 17,904 bp of genomic DNA comprising 15 exons. We also mapped the transcription initiation site to a consensus initiator element proximal to an SP1 site. Approximately 1 kb of sequence upstream of the transcription initiation site confers promoter activity and cell type specificity to a reporter gene construct. Surprisingly, transcription from this promoter was repressed by over-expression of catalytically active but not catalytically inactive CDC25A protein. We also show, using NIH 3T3 cells, that murine CDC25A mRNA levels fluctuate only modestly over the cell cycle. Our findings provide insights into the regulation of CDC25A expression and have facilitated construction of gene knock-out vectors.

Opinions and use of advance directives by physicians at a tertiary care hospital

The physician-patient relationship is an essential part of end-of-life planning, including discussions of advance directives (AD). Physicians likely to encounter AD issues with their patients were identified and queried as to their knowledge, opinion, and experience with ADs. Though most physicians felt ADs were helpful to both physicians and patients, considerably less were familiar with hospital policies and the different types of ADs. Formal education in the use and function of ADs also appears to be lacking, suggesting a need to improve the way in which ADs are addressed during medical training.

Evaluation of novel assays in clinical chemistry: quantification of plasma total homocysteine

BACKGROUND

There is a need for systematic evaluation of methods before their release to the market. We addressed this problem in novel homocysteine assays as part of an European Demonstration Project involving six centers in four countries.

METHODS

Two immunological methods for measurement of plasma total homocysteine (P-tHcy), the fluorescence polarization immunoassay (FPIA) and the enzyme immunoassay (EIA), were compared with two comparison methods, HPLC and gas chromatography-mass spectrometry (GC-MS). All laboratories performed the following procedures: (a) familiarization; (b) determination of linearity and precision by analyzing five plasma samples with interrelated concentrations for 20 days; (c) correlation using patients' samples; and (d) assessment of long-term performance.

RESULTS

Both immunological methods were linear for P-tHcy between 5 and 45 micromol/L. The intralaboratory imprecision (CV) was <5% for FPIA and <9% for EIA used with a sample processor. The bias was -2% to 3% for FPIA and 2-4% for EIA used with a sample processor.

CONCLUSIONS

The immunological methods provide results with little bias compared with HPLC and GC-MS. The imprecision of the assays must be considered in the context of their intended use(s).

Effects of stimulant medication treatment on mothers' and children's attributions for the behavior of children with attention deficit hyperactivity disorder

Participants were 55 children with attention deficit hyperactivity disorder (ADHD) who were receiving ongoing treatment with stimulant medications and their mothers, and 31 children with ADHD who were beginning stimulant medication and their mothers. Mothers and children offered attributions for child behaviors that occurred when the child was medicated and not medicated. Mothers rated child compliance and prosocial behavior as more global and stable when the child was medicated and rated noncompliance, ADHD symptoms, and oppositional behavior as more externally caused, less global and stable, but more controllable by the child when the child was medicated. Children rated both their compliance and noncompliance as more controllable in the medicated condition. On a forced-choice measure, both mothers and children selected ability, effort, and task attributions for compliance more in the not-medicated condition, and pill-taking attributions more in the medicated condition. This was reversed for noncompliance, which was attributed more to effort, task, or ability in the medicated condition and more to not taking a pill in the not-medicated condition. The potential risks and benefits for parent-child interactions and children's self-perceptions of these medication-related differences in attributions are discussed.

Acute pulmonary effects of ultrafine particles in rats and mice

Ambient fine particles consist of ultrafine particles (< 100 nm) and accumulation-mode particles (approximately 100 to 1,000 nm). Our hypothesis that ultrafine particles can have adverse effects in humans is based on results of our earlier studies with particles of both sizes and on the finding that urban ultrafine particles can reach mass concentrations of 40 to 50 micrograms/m3, equivalent to number concentrations of 3 to 4 x 10(5) particles/cm3. The objectives of the exploratory studies reported here were to (1) evaluate pulmonary effects induced in rats and mice by ultrafine particles of known high toxicity (although not occurring in the ambient atmosphere) in order to obtain information on principles of ultrafine particle toxicology; (2) characterize the generation and coagulation behavior of ultrafine particles that are relevant for urban air; (3) study the influence of animals' age and disease status; and (4) evaluate copollutants as modifying factors. We used ultrafine Teflon (polytetrafluoroethylene [PTFE]*) fumes (count median diameter [CMD] approximately 18 nm) generated by heating Teflon in a tube furnace to 486 degrees C to evaluate principles of ultrafine particle toxicity that might be helpful in understanding potential effects of ambient ultrafine particles. Teflon fumes at ultrafine particle concentrations of approximately 50 micrograms/m3 are extremely toxic to rats when inhaled for only 15 minutes. We found that neither the ultrafine Teflon particles alone when generated in argon nor the Teflon fume gas-phase constituents when generated in air were toxic after 25 minutes of exposure. Only the combination of both phases when generated in air caused high toxicity, suggesting the existence of either radicals on the particle surface or a carrier mechanism of the ultrafine particles for adsorbed gas-phase compounds. We also found rapid translocation of the ultrafine Teflon particles across the epithelium after their deposition, which appears to be an important difference from the behavior of larger particles. Furthermore, the pulmonary toxicity of the ultrafine Teflon fumes could be prevented by adapting the animals with short 5-minute exposures on 3 days prior to a 15-minute exposure. This shows the importance of preexposure history in susceptibility to acute effects of ultrafine particles. Aging of the fresh Teflon fumes for 3.5 minutes led to a predicted coagulation resulting in particles greater than 100 nm that no longer caused toxicity in exposed animals. This result is consistent with greater toxicity of ultrafine particles compared with accumulation-mode particles. When establishing dose-response relationships for intratracheally instilled titanium dioxide (TiO2) particles of the size of the urban ultrafine particles (20 nm) and of the urban accumulation-mode particles (250 nm), we observed significantly greater pulmonary inflammatory response to ultrafine TiO2 in rats and mice. The greater toxicity of the ultrafine TiO2 particles correlated well with their greater surface area per mass. Ultrafine particles of carbon, platinum, iron, iron oxide, vanadium, and vanadium oxide were generated by electric spark discharge and characterized to obtain particles of environmental relevance for study. The CMD of the ultrafine carbon particles was approximately 26 nm, and that of the metal particles was 15 to 20 nm, with geometric standard deviations (GSDs) of 1.4 to 1.7. For ultrafine carbon particles, approximately 100 micrograms/m3 is equivalent to 12 x 10(6) particles/cm3. Homogeneous coagulation of these ultrafine particles in an animal exposure chamber occurred rapidly at 1 x 10(7) particles/cm3, so that particles quickly grew to sizes greater than 100 nm. Thus, controlled aging of ultrafine carbon particles allowed the generation of accumulation-mode carbon particles (due to coagulation growth) for use in comparative toxicity studies. We also developed a technique to generate ultrafine particles consisting of the stable isotope 13C by using 13C-graphite electrodes made in our laboratory from amorphous 13C powder. These particles are particularly useful tools for determining deposition efficiencies of ultrafine carbon particles in the respiratory tracts of laboratory animals and the translocation of particles to extrapulmonary sites. For compromised animals, we used acute and chronic pulmonary emphysema; a low-dose endotoxin inhalation aimed at priming target cells in the lung was also developed. Other modifying factors were age and copollutant (ozone) exposure. Exposure concentrations of the generated ultrafine particles for acute rodent inhalation studies were selected on the basis of lung doses predicted to occur in people inhaling approximately 50 micrograms/m3 urban ultrafine particles. Concentrations that achieved the same predicted lung burden per unit alveolar surface were used in rodents. (ABSTRACT TRUNCATED)

A preliminary report of the use of botulinum toxin type A in infants with clubfoot: four case studies

This report describes the use of botulinum toxin type A (BTX-A) in four infants with very severe clubfoot deformity. The gastrocnemius and posterior tibial muscles were injected with BTX-A after the patients reached a treatment plateau in physical therapy. Significant improvement in foot dorsiflexion and foot flexibility was seen in two patients, and surgery was not required. Surgical intervention was necessary in the remaining two patients, both of whom were ultimately diagnosed with a demyelinating neuropathy. The use of botulinum toxin as an adjunct to conservative care in infants with clubfoot is discussed.

Is high titre ANA specific for connective tissue disease?

OBJECTIVE

A positive antinuclear antibody (ANA), while sensitive, is not specific for systemic lupus erythematosus or connective tissue diseases (CTD). The purpose of the present study was to review those sera with a high titre (> or = dilutions above screening) ANA and determine from a review of the charts if these higher titres offered a satisfactory specificity for CTD.

METHODS

All FANA testing in this region is carried out in one of two related laboratories. We reviewed the medical records of patients who had a positive ANA at a titre 4 dilutions above screening at this city-wide laboratory over a 6-month period to determine whether this titre ("high titre") may offer relative diagnostic certainty. Antibodies to extractable nuclear antigens (ENA) and native DNA were also obtained.

RESULTS

422 ANA results were positive at high titre. The medical record was available for review in 320 patients, of whom 238 (75%) were seen by a specialist physician, almost always including a rheumatologist. Our review determined that 35% had a diagnosis of connective tissue disease, 21% had a diagnosis of a possible/probable inflammatory disease, 16% had an alternative specific diagnosis provided, and in 29% no final disease specific diagnosis was recorded but CTD was not suggested to us or the specialist by the data available. One or more anti-ENA antibodies and/or anti-DNA were positive in 69 (22%) and 8% of the sera tested respectively.

CONCLUSION

While long term follow-up is still required, a significant proportion of patients with high titre ANA have no CTD at the time of testing. Setting a higher cutoff for reporting of ANA may not increase specificity sufficiently to make it a useful alternative or addition to reporting a positive or negative value at screening titre alone.

Northwest Herts diabetic management system

The Diabetic Management System was set up in Hemel Hempstead within the Dacorum district (population 119515 with 2176 registered patients with diabetes). The objective was to create a clinical management system for all patients with diabetes in a district using a computerised clinical base. To achieve this a database of agreed clinical information was collected from all general practitioners within the district. From the computerised data we can identify those patients who do not have data recorded and can recall them for review. Consultant advice can be given on patients with special or multiple risks identified from interrogation of the database. The outcome has been a higher percentage of patients with diabetes receiving clinical review and achieving optimal clinical targets within the reviews. We already have recorded data on 85% for retinal screening and 75% for comprehensive annual reviews. Conclusions drawn from the Dacorum Diabetic Management System are that effective diabetic care to a population can be provided by a combination of hospital and primary care. Primary care needs to be supported by adequate consultant advice with continued monitoring of the whole population to ensure standards are met. This system achieves this without increased hospital referrals.

Basic three-dimensional kinematics of the vertebral column of horses walking on a treadmill

OBJECTIVE

To determine kinematic movements of the vertebral column of horses during normal locomotion.

ANIMALS

5 Dutch Warmblood horses without apparent lameness or problems associated with the vertebral column.

PROCEDURE

Kinematics of 8 vertebrae (T6, T10, T13, T17, L1, L3, L5, and S3) and both tuber coxae were determined, using bone-fixated markers. Horses were recorded while walking on a treadmill at a constant speed of 1.6 m/s.

RESULTS

Flexion-extension was characterized by 2 periods of extension and flexion during 1 stride cycle, whereas lateral bending and axial rotation were characterized by 1 peak and 1 trough. The range of motion for flexion-extension was fairly constant for vertebrae caudal to T10 (approximately 7 degrees). For lateral bending, the cranial thoracic vertebrae and segments in the pelvic region had the maximal amount of motion, with values of up to 5.6 degrees. For vertebrae between T17 and L5, the amount of lateral bending decreased to <4 degrees The amount of axial rotation increased gradually from 4 degrees for T6 to 13 degrees for the tuber coxae.

CONCLUSIONS

This direct measurement method provides 3-dimensional kinematic data for flexion-extension, lateral bending, and axial rotation of the thoracolumbar portion of the vertebral column of horses walking on a treadmill. Regional differences were observed in the magnitude and pattern of the rotations. Understanding of the normal kinematics of the vertebral column in healthy horses is a prerequisite for a better understanding of abnormal function.