Outcome of foot injuries in multiply injured patients

In the past, foot injuries in patients with multiple trauma were thought to be of lesser importance than fractures of long bones. In one prospective study from the authors' institutions, however, multiple-trauma patients with foot injuries were shown to have a poorer functional outcome compared with matched controls. To address these concerns, this article has two parts. The first part is an overview of general principles in the treatment of foot injuries in polytrauma patients. The treatment of specific injuries is beyond the scope of this article, but an approach is highlighted that can be remembered when decisions are made regarding these severely injured patients. The second part reviews the findings from the authors' study, focusing on functional outcomes of multiple-trauma patients with foot injuries.

Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach

BACKGROUND

While surgical repair is considered the standard of care of displaced intra-articular distal humeral fractures, most investigators have assessed its results with use of surgeon-based and/or radiograph-based outcome measures. The purpose of our study was to determine the functional outcome of fixation of displaced intra-articular distal humeral fractures with use of a standardized evaluation methodology consisting of objective testing of muscle strength and use of patient-based questionnaires (both limb-specific and general health-status questionnaires).

METHODS

We identified twenty-five patients (fourteen male and eleven female), with a mean age of forty-seven years, who had an isolated, closed, displaced, intercondylar, intra-articular fracture of the distal part of the humerus repaired operatively through a posterior approach and fixed with plates on both the medial and the lateral column. All patients returned for follow-up that included recording of a complete history, physical examination, radiographic examination, completion of both a limb-specific questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]) and a general health-status questionnaire (Short Form-36 [SF-36]), and objective muscle-strength testing.

RESULTS

The mean duration of follow-up was thirty-seven months (range, eighteen to seventy-five months). The mean flexion contracture was 25 degrees (range, 5 to 65 degrees), and the mean arc of flexion-extension was 108 degrees (range, 55 to 140 degrees). Significant decreases in mean muscle strength compared with that on the normal side were seen in both elbow flexion measured at 90 degrees (74 percent of normal, p = 0.01) and elbow extension measured at 45 degrees (76 percent of normal, p = 0.01), 90 degrees (74 percent of normal, p = 0.01), and 120 degrees (75 percent of normal, p = 0.01). The mean DASH score was 20 points, indicating mild residual impairment. The SF-36 scores revealed minor but significant decreases in the role-physical and physical function scores (p = 0.01 and 0.03, respectively) but no alteration of the mental component or mean scores. Six patients (24 percent) had a reoperation; three of them had removal of prominent hardware used to fix the site of an olecranon osteotomy.

CONCLUSIONS

The surgical repair of an intra-articular distal humeral fracture is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. Our study quantified a decrease in the range of motion and muscle strength of these patients, which may help to explain the mild residual physical impairment detected by the limb-specific outcome measures and physical function components of the general health-status measures.

Phosphate regulation of vascular smooth muscle cell calcification

Vascular calcification is a common finding in atherosclerosis and a serious problem in diabetic and uremic patients. Because of the correlation of hyperphosphatemia and vascular calcification, the ability of extracellular inorganic phosphate levels to regulate human aortic smooth muscle cell (HSMC) culture mineralization in vitro was examined. HSMCs cultured in media containing normal physiological levels of inorganic phosphate (1.4 mmol/L) did not mineralize. In contrast, HSMCs cultured in media containing phosphate levels comparable to those seen in hyperphosphatemic individuals (>1.4 mmol/L) showed dose-dependent increases in mineral deposition. Mechanistic studies revealed that elevated phosphate treatment of HSMCs also enhanced the expression of the osteoblastic differentiation markers osteocalcin and Cbfa-1. The effects of elevated phosphate on HSMCs were mediated by a sodium-dependent phosphate cotransporter (NPC), as indicated by the ability of the specific NPC inhibitor phosphonoformic acid, to dose dependently inhibit phosphate-induced calcium deposition as well as osteocalcin and Cbfa-1 gene expression. With the use of polymerase chain reaction and Northern blot analyses, the NPC in HSMCs was identified as Pit-1 (Glvr-1), a member of the novel type III NPCs. These data suggest that elevated phosphate may directly stimulate HSMCs to undergo phenotypic changes that predispose to calcification and offer a novel explanation of the phenomenon of vascular calcification under hyperphosphatemic conditions. The full text of this article is available at http://www.circresaha.org.

Identification and localization of lysozyme as a component of eggshell membranes and eggshell matrix

The avian eggshell is a composite biomaterial composed of non-calcifying eggshell membranes and the overlying calcified shell matrix. The calcified shell forms in a uterine fluid where the concentration of different protein species varies between the initial, rapid calcification and terminal phases of eggshell deposition. The role of these avian eggshell matrix proteins during shell formation is poorly understood. The properties of the individual components must be determined in order to gain insight into their function during eggshell mineralization. In this study, we have identified lysozyme as a component of the uterine fluid by microsequencing, and used western blotting, immunofluorescence and colloidal-gold immunocytochemistry to document its localization in the eggshell membranes and the shell matrix. Furthermore, Northern blotting and RT-PCR indicates that there is a gradient to the expression of lysozyme message by different regions of the oviduct, with significant albeit low levels expressed in the isthmus and uterus. Lysozyme protein is abundant in the limiting membrane that circumscribes the egg white and forms the innermost layer of the shell membranes. It is also present in the shell membranes, and in the matrix of the calcified shell. Calcite crystals grown in the presence of purified hen lysozyme exhibited altered crystal morphology. Therefore, in addition to its well-known anti-microbial properties that could add to the protective function of the eggshell during embryonic development, shell matrix lysozyme may also be a structural protein which in soluble form influences calcium carbonate deposition during calcification.

Use of a hinged external fixator for elbow instability after severe distal humeral fracture

The authors report the case of a forty-year-old man who developed acute elbow instability after fixation of an open, comminuted distal humeral fracture. Treatment with a hinged, external elbow fixator was successful in reestablishing elbow stability and a functional range of elbow motion. To the best of the authors' knowledge, the use of this device for acute elbow instability after distal humeral fracture fixation has not been previously reported.

Mature full-thickness articular cartilage explants attached to bone are physiologically stable over long-term culture in serum-free media

Mature tissue explants containing the entire depth of articular cartilage, calcified and uncalcified, attached to a thin layer of subchondral bone were isolated from bovine humeral heads of 1-2-year-old steers. These explants were placed in defined serum-free culture medium for a period of 3 weeks to investigate their biological and mechanical stability and thus to determine their potential utility in studies of cartilage physiology. Tissue mass remained constant over the culture period and no evident tissue swelling or distortion was observed. Chondrocytes were viable in all zones at the time of tissue isolation and throughout the culture period, with the exception of a thin layer of cells at the articular surface and the cut radial edge of the disks. Proteoglycan metabolism attained a steady state after 5 days of culture when the rate of loss of proteoglycan to culture media was compensated by new synthesis to maintain a stable proteoglycan content. Collagen metabolism was also stable with a constant content of type II collagen and a constant content of denatured collagen II throughout culture; the content of the C-propeptide of type II procollagen as a measure of procollagen synthesis, dropped slightly during the first week to attain a steady state after that time. Dynamic and equilibrium mechanical properties of these explant disks were also stable confirming maintenance of these tissue properties during long-term culture. In addition, the disk geometry of the system, with the cut surface in the bone parallel to the intact articular surface, is well-suited to study tissue regulation by mechanical load. Taken together, the stability of these indicators of tissue physiology indicates the maintenance in serum-free conditions of normal metabolism for organ cultures containing full-depth mature articular cartilage attached to bone.

Quantitation of T-cell receptor frequencies by competitive polymerase chain reaction: dynamics of T-cell clonotype frequencies in an expanding tumor-infiltrating lymphocyte culture

The use of T-cell receptor (TCR) genes as markers for antigen-reactive T cells is dependent on the ability of the TCR genes to rapidly identify antigen-reactive T-cell clonotypes in patient samples. We recently reported a competitive reverse-transcriptase polymerase chain reaction (cRT-PCR) method that can measure the frequency of individual TCRBV subfamilies and clonotypes in mixed lymphocyte populations more accurately than other semiquantitative PCR assays. However, it is impractical to measure changes in the absolute frequency of each TCRBV subfamily to identify those T cells with increasing frequency after antigen stimulation in vivo or in vitro. Therefore, we have modified our cRT-PCR method to more rapidly identify expanding T-cell populations by combining all of the TCRBV subfamily-specific competitors into a single sample to determine the relative abundance of each TCRBV subfamily. Using an expanding TIL 620 culture, we identified four TCRBV (BV2, BV12, BV17, and BV23) subfamilies that expanded over a 23-day period. These subfamilies accounted for 23% of the T cells in the day 35 culture and increased to 57%, 92%, and 80% of the days 44, 51, and 58 cultures respectively. Analysis of DNA sequences demonstrated that the observed expansion was caused primarily by a single clonotype within each subfamily. T cells expressing BV17 and BV23 recognized gp100 and MART-1 respectively. Therefore, this cRT-PCR method can detect expanding T-cell populations based solely on their TCRBV subfamily expression. Furthermore, T-cell expansion in a mixed TIL population was a good predictor of antigen reactivity.

Functional outcome after open supracondylar fractures of the humerus. The effect of the surgical approach

We reviewed 26 patients who had had internal fixation of an open intra-articular supracondylar fracture of the humerus. All operations were performed using a posterior approach, 13 with a triceps split and 13 with an olecranon osteotomy. The outcome was assessed by means of the Mayo Elbow score, the Disability of the Arm, Shoulder and Hand (DASH) score and the SF-36 Physical Function score. Patients with an olecranon osteotomy had less good results.

The effect of surgery for rotator cuff disease on general health status. Results of a prospective trial

BACKGROUND

Previous studies of the effect of rotator cuff surgery have concentrated on limb-specific or surgeon-based outcome criteria. We conducted a prospective trial to determine the effect of surgery for rotator cuff disease on general health status.

METHODS

Seventy-one patients (fifty of whom were men and twenty-one of whom were women) with a mean age of 56.1 years were enrolled in the study. In addition to routine clinical and radiographic evaluation, all patients completed the Short Form-36 (SF-36) health-status questionnaire and five limb-specific questionnaires preoperatively and at six, twelve, eighteen, and twenty-four months postoperatively. All patients had a standard open acromioplasty and resection of the subacromial bursa. Thirty-one patients had repair of an associated rotator cuff tear. Sixty-seven patients (94 percent) completed the study; the remaining four patients were lost to follow-up.

RESULTS

The preoperative SF-36 scores for physical function (60.6, p = 0.02), role function-physical (20.8, p = 0.001), pain (38.6, p = 0.003), physical component summary (37.0, p = 0.001), and mental component summary (45.6, p = 0.02) were significantly decreased compared with normative data. The preoperative limb-specific scores also were low. At the time of the most recent follow-up evaluation, there was improvement that approached or reached significance both in the limb-specific scores (p < or = 0.0026) and in the general-health-status scores for pain (p = 0.0001), role function-physical (p = 0.06), vitality (p = 0.01), and physical component summary (p = 0.01). The presence of a rotator cuff tear had a significant negative effect on limb-specific scores both preoperatively (p = 0.04) and postoperatively (p = 0.05). Although operative treatment of rotator cuff disease led to improved scores, patients who had filed a Workers' Compensation claim had lower limb-specific and SF-36 scores both preoperatively (p = 0.02 and p = 0.01, respectively) and postoperatively (p = 0.01 and p = 0.005, respectively).

CONCLUSIONS

Surgery for chronic rotator cuff disease reliably and significantly improves general health status.

Donor site morbidity following vascularized fibular grafting

We examined donor site morbidity in thirty-nine patients with avascular necrosis of the femoral head treated by curettage and transplantation of a free ipsilateral fibular graft. Utilising our donor site morbidity questionnaire, scar, functional loss, wound healing, complications, and pain were analysed. Subjective complaints and objective findings were evaluated and compared. Subjective complaints were common and included a sense of instability in 42% and a sense of weakness in 37%. However, objective findings were limited. No clinical instability could be elicited and only great toe flexion (29%) and extension (43%) were found to be mildly weak. Only one patient required reoperation for a donor site problem (2%). Eighty-nine percent were pain free at time of follow-up, and 93% felt the scar was good. Range of motion of the knee and ankle of the donor site leg was not different from the nonoperated leg. Donor site morbidity for avascular necrosis of the femoral head is low.

Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial

We randomised prospectively 44 patients with fractures of the shaft of the humerus to open reduction and internal fixation by either an intramedullary nail (IMN) or a dynamic compression plate (DCP). Patients were followed up for a minimum of six months. There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons' score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. There was a single case of shoulder impingement in the DCP group and six in the IMN group. Of these six, five occurred after antegrade insertion of an IMN. In the DCP group three patients developed complications, compared with 13 in the IMN group. We had to perform secondary surgery on seven patients in the IMN group, but on only one in the DCP group (p = 0.016). Our findings suggest that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.

Operative treatment of nonunions about the elbow

Nonunions about the elbow present a great challenge to the orthopaedic surgeon. Recent advances have enabled the surgeon to achieve much improved results. The current study outlines the treatment of nonunions of the distal humerus, proximal ulna (including olecranon, Monteggia, and coronoid nonunions), and radial head and neck nonunions. The historic problems of treating these nonunions included the use of inadequate fixation, the poor understanding of the role of soft tissue surgery in the treatment of the stiff elbow, and the failure of previous postoperative rehabilitation protocols. Advances made in the techniques of soft tissue treatment, modern methods of stable internal fixation, and early postoperative rehabilitation all have made an exceptional difference in the surgeon's ability to treat these most complex problems. The current study will provide the reader with a greater understanding of nonunions about the elbow, clinical and technical details for their treatment, and the expected results after treatment.

Fractures of capitellum and trochlea

The principles of management of capitellar and trochlear fractures are similar to any other intra-articular fracture. Accurate anatomic reduction, rigid internal fixation, and early mobilization of the elbow are prerequisites for a good functional result. Small fragments with minimal subchondral bone, not amenable to rigid internal fixation, are best treated by surgical resection. This article outlines the diagnosis, treatment, controversies, postoperative results, and complications of these rare elbow fractures.

Antibiotic use for the treatment of upper respiratory infections in a diverse community

BACKGROUND

Previous studies have not addressed whether cultural factors influence beliefs and practices related to the treatment of upper respiratory infections (URIs). The purpose of our project was to assess beliefs, care-seeking behavior, use of antibiotics, and means of obtaining antibiotics for the treatment of URIs among different ethnic groups in an urban community.

METHODS

A total of 192 adults completed a self-administered questionnaire indicating their likelihood of seeking care, the perceived effectiveness of treatment methods, and their usual use of treatment regimens for 2 scenarios consistent with uncomplicated URIs. Respondents were also asked about their use of antibiotics not prescribed by a physician for a URI.

RESULTS

A majority of subjects reported a belief in the effectiveness of antibiotics for URIs and indicated they are likely to seek care for URIs. Many (26%) had obtained antibiotics from sources other than a physician's prescription (e.g., directly from pharmacists or a supplier outside the United States). Many (31%) believed that antibiotics should be available over the counter. Individuals who reported using antibiotics for a URI were more likely than those who did not to obtain them without a prescription (35% vs. 11%, P = .001). Subjects with a cultural background from countries where antibiotics are available over the counter are more likely to use antibiotics not prescribed by a physician than those from countries with variably enforced regulations or the United States (40%, 30%, and 20%, respectively, P = .049).

CONCLUSIONS

Members of an ethnically diverse community believe antibiotics are effective for colds, are very likely to seek care for colds, and often obtain antibiotics without a prescription. The ease of antibiotic access worldwide may influence their use in some communities in the United States.

Molecular cloning and ultrastructural localization of the core protein of an eggshell matrix proteoglycan, ovocleidin-116

The role of avian eggshell matrix proteins in shell formation is poorly understood. This calcitic biomaterial forms in a uterine fluid where the protein composition varies during the initial, calcification, and terminal phases of eggshell deposition. A specific antibody was raised to a 116-kDa protein, which is most abundant in uterine fluid during active eggshell calcification. This antiserum was used to expression screen a bacteriophage cDNA library prepared using mRNA extracted from pooled uterine tissue harvested at the midpoint of eggshell calcification. Plasmids containing inserts of differing 5'-lengths were isolated with a maximum cDNA sequence of 2.4 kilobases. Northern blotting and reverse transcriptase-polymerase chain reaction demonstrated that the 2. 35-kilobase message was expressed in a uterine-specific manner. The hypothetical translational product from the open reading frame corresponded to a novel 80-kDa protein, which we have named ovocleidin-116. After removal of the predicted signal peptide, its N-terminal sequence corresponded almost exactly with that determined from direct microsequencing of the 116-kDa uterine protein (this work) and with that previously determined for the core protein of a 120-kDa eggshell dermatan sulfate proteoglycan (Corrino, D. A., Rodriguez, J. P., and Caplan, A. I. (1997) Connect. Tissue Res. 36, 175-193). Ultrastructural colloidal gold immunocytochemistry of ovocleidin-116 demonstrated its presence in the organic matrix, in small vesicles found throughout the mineralized palisade layer, and the calcium reserve assembly of the mammillary layer. Ovocleidin-116 thus is a candidate molecule for the regulation of calcite growth during eggshell calcification.

Early detection of arterial bleeding in acute pelvic trauma

OBJECTIVE

To determine the accuracy of intravenous contrast-enhanced computerized tomography (CECT) in the detection of potentially life-threatening retroperitoneal hemorrhage in patients sustaining pelvic fractures, acetabular fractures or both.

DESIGN

Retrospective review of sequential patients identified over a 1-year period by using a prospectively collected trauma database at two Level I trauma centers.

MATERIALS AND METHODS

A group of patients admitted to one of two Level I trauma centers with pelvic or acetabular injuries between September 1, 1995, and September 30, 1996, was identified by using a prospectively collected trauma database. From this cohort, we selected those individuals who had undergone intravenous CECT scanning within 24 hours after admission and who had an Abbreviated Injury Score more than 3 because of their pelvic injury. Those individuals who required arterial embolization for uncontrolled hemodynamic shock were categorized as having "significant arterial bleeding" attributable to their pelvic injury. Individuals who regained hemodynamic ,stability without embolization were categorized as having "no significant arterial bleeding." Two observers who were blinded to clinical information and the results of angiography reviewed all injury radiographs and computed tomographic scans. The presence or absence of contrast extravasation on intravenous CECT was recorded. Each case was then categorized into a 2 x 2 table depending on the presence of contrast extravasation on CECT and the need for arterial embolization to determine the accuracy of the "contrast extravasation sign."

RESULTS

Of the 192 eligible patients, 111 met the inclusion criteria. Eleven patients required an angiogram for ongoing hemodynamic instability. The sensitivity of extravasation on contrast enhanced computed tomography representing a significant arterial bleeding was 80%, and the specificity was 98%. The predictive value of a positive contrast "extravasation sign" was 80%, whereas the predictive value of a negative test was 98%. The likelihood ratio of a positive test was 40.4, and the likelihood ratio of a negative test was 0.204.

CONCLUSION

The finding of contrast extravasation on CECT is highly suggestive of significant arterial bleeding that requires early angiographic embolization to restore hemodynamic stability.

A prospective, randomized clinical trial comparing tibial nailing using fracture table traction versus manual traction

OBJECTIVE

We sought to determine the effectiveness of intramedullary tibial nailing using manual traction with the leg draped free versus standard fracture table positioning and traction.

STUDY DESIGN

Prospective, randomized clinical trial.

METHODS

Eighty-five tibial shaft fractures (in seventy-nine patients) treated by intramedullary nailing were randomized either to manual traction with the leg draped free or to standard fracture table traction applied through a boot attachment.

RESULTS

We found that manual traction provided results, in terms of intraoperative parameters and quality of fracture reduction, similar to those with standard fracture table traction. Manual traction significantly reduced positioning time (twelve minutes versus twenty-five minutes, p = 0.002) and also allowed for multiple simultaneous or sequential procedures in polytrauma patients without the need for re-positioning or re-draping. This saved a further thirty-two minutes (mean) in 37 percent of cases treated by manual traction.

CONCLUSION

Manual traction for intramedullary nailing of the tibia is an effective technique that can save a significant amount of time without sacrificing the quality of reduction or fixation of tibial shaft fractures. It is especially useful in polytrauma patients with multiple lower-extremity injuries.

Treatment of osteonecrosis of the femoral head by free vascularized fibular grafting: an analysis of surgical outcome and patient health status

OBJECTIVE

To evaluate the limb-specific outcome and general health status of patients with osteonecrosis of the femoral head treated with vascularized fibular grafting.

DESIGN

A retrospective review.

SETTING

A single tertiary care centre.

PATIENTS

Fifty-five consecutive patients with osteonecrosis of the femoral head who underwent fibular grafting (8 bilaterally).

INTERVENTION

Vascularized fibular grafting.

OUTCOME MEASURES

Limb-specific scores (Harris Hip Score, St. Michael's Hospital Hip Score), general health status (Nottingham Health Profile, SF-36 health status survey) and radiographic outcome measures (Steinberg stage).

RESULTS

Patients were young (mean age 34 years, range from 18 to 52 years) and 80% had advanced osteonecrosis (Steinberg stages IV and V). Fifty-nine hips were followed up for an average of 50 months (range from 24 to 117 months) after vascularized fibular grafting. Sixteen hips (27%) were converted to total hip arthroplasty (THA). To date, 73% of hips treated with vascularized fibular grafting have required no further surgery. Preoperative and postoperative Harris Hip Scores were 57.3 and 83.6 respectively (p < 0.001). As measured by patient-oriented health status questionnaires (SF-36, Nottingham Health Profile) and compared with population controls, patients had normal mental health scores and only slight decreases in physical component scores.

CONCLUSIONS

Free vascularized fibular grafting for osteonecrosis of the femoral head provides satisfactory pain relief, functional improvement and general health status and halts the progression of symptomatic disease.

Complications of intramedullary nailing for fractures of the humeral shaft: a review

OBJECTIVES

The purpose of the present review is to document the complications associated with the use of locking humeral nails and to discuss the prevention and management of these complications.

DATA SOURCES

Clinical and research experience supported by a Medline review of the English-language literature from 1985 to 1998.

STUDY SELECTION

The majority of (clinical) information available was contained in retrospective reviews; only three prospective or randomized studies were identified (all in abstract form). Anatomical research regarding locking humeral nailing was also identified and included.

DATA EXTRACTION

Because there were so few prospective studies available, a formal meta-analysis of data was not performed. This review focuses on a descriptive assessment of available information on specific complication-related topics.

CONCLUSIONS

The attractive theoretical advantages of locking humeral nails have not been borne out in clinical studies. Complications such as shoulder pain, delayed union or nonunion, fracture about the implant, iatrogenic fracture comminution, and the difficulty in the reconstruction of failures have diminished their usefulness. The precise role of locking nails in the treatment of humeral shaft fractures has yet to be defined. At present, open reduction and compression plating remain the treatment of choice for humeral shaft fractures that require operative intervention.

Quantitation of T-cell receptor frequencies by competitive PCR: generation and evaluation of novel TCR subfamily and clone specific competitors

T cell receptor (TCR) V gene usage has been used to characterize the immune response to bacteria, viruses, allografts, self antigens, tumor antigens, and superantigens. Sensitive methods to detect changes in the frequency of TCR subfamilies or clonotypes might be useful in evaluating the efficacy of vaccines against infectious agents, immunotherapy treatments for cancer patients, or the status of autoimmune diseases. Two HLA-A2 restricted CTL clones expressing BV17 were isolated from a tumor infiltrating lymphocytes (TIL) culture of a patient with metastatic melanoma. One clone recognized the MART-1(27-35) peptide and the other clone recognized the gp100(209-217) peptide. The frequency of each of these CTL clones in an expanding TIL culture was measured using a novel competitive RT-PCR (cRT-PCR) strategy. cRT-PCR uses a single primer pair to amplify template cDNA simultaneously with a modified DNA competitor molecule. A rapid two-step PCR technique followed by a single cloning step was used to generate a TCR BV17 subfamily specific competitor or competitors specific for the MART-1(27-35) reactive CTL clone (CO-41) and the gp100(209-217) reactive CTL clone (CO-4). Each competitor contained a segment of the TCR BC region that served as an internal reference standard. Using the BV17 competitor we were able to accurately and reproducibly measure cDNA templates at a frequency as low as 1/100,000 using cDNA samples of known TCRBV subfamily composition. This competitor was used to monitor the frequency of BV17 expressing T cells in the TIL and PMBC of a patient with metastatic melanoma. We determined that the frequency of BV17 expressing T cells increased from 4.5% of the culture on day 35 to 60.7% of the culture on day 58. Expansion of the BV17 subfamily was due predominantly to the expansion of the CO-4 clone. This method can be used to meaningfully quantify the precursor frequency of T cell mRNA in prepared samples via TCR subfamily or TCR sequence specific primers.

Barriers to follow-up of abnormal Papanicolaou smears in an urban community health center

OBJECTIVE

To determine factors predictive of failure to return for colposcopy among women with significant abnormalities on Papanicolaou smears in a high-risk clinical population.

DESIGN

Telephone survey.

SETTING

An urban community health center.

PARTICIPANTS

Two hundred seventy-nine women randomly selected from all women seen at the health center with abnormal Papanicolaou smears requiring colposcopy during 1993 to 1994. Six (2%) refused participation, and 19% could not be reached for inclusion. Subjects were mostly minority women receiving Medicaid.

MAIN OUTCOME MEASURE

Completion of colposcopy.

RESULTS

Of the 279 selected women, 79% were interviewed. The rate of adherence with colposcopy was 75% for the respondents. Women who did not know the results of their smear or who incorrectly understood their results were significantly less likely to return for colposcopy (P = .001). Younger women, especially teenagers, were less likely to return (P = .02). Socioeconomic status, education, primary language, health beliefs, fear of cancer, and clinician's gender or discipline were not associated with rate of follow-up. Barriers involving transportation, child care, and insurance also did not predict follow-up.

CONCLUSIONS

Effective communication of results is the most important factor related to follow-up after abnormal Papanicolaou smear in this setting. In other settings, other factors may be of greater importance.