Risk of extra-oesophageal malignancies and colorectal cancer in Barrett's oesophagus and gastro-oesophageal reflux

BACKGROUND

The relationship between Barrett's oesophagus and colorectal cancer and other extra-oesophageal malignancies (EOM) has been a matter of controversy. These relationships have therefore been examined in a prospective study design in the General Practice Research Database.

METHODS

Cohorts of patients having Barrett's oesophagus (n=1677), oesophagitis (n=6392), and simple reflux (n=6328), and a standard reference cohort representing the general population in the UK (n=13,416) were selected. The last three cohorts were matched to the Barrett's cohort by general practice, age and sex. Incident outcomes occurring beyond the first year of the follow-up were used for analyses. Hazard ratios and 95% confidence intervals were calculated using Cox's proportional hazards regression. The associations with cataract and oesophageal cancer were explored for comparison.

RESULTS

Incident cases of 567 EOM (including 74 colorectal cancers), 448 cataract and 43 oesophageal cancers were used in the final analysis. The relative risks for colorectal cancer compared to the standard reference cohort were 1.16 (0.42-3.21) in the Barrett's cohort, 1.39 (0.76-2.54) in the oesophagitis cohort, and 0.93 (0.45-1.90) in the simple reflux cohort. The corresponding relative risks in the Barrett's cohort were 1.29 (0.90-1.85), 1.60 (1.10-2.32), and 10.56 (5.07-21.99) for EOM, cataract and oesophageal cancer, respectively.

CONCLUSIONS

The risk of colorectal cancer was not higher in any of the Barrett's oesophagus, oesophagitis, or reflux cohorts compared to the general population. The explanations for the modest increase in the risk of EOM and cataract in the above cohorts are unclear but they may be mediated by ascertainment bias or shared risk factors.

Screening for visual impairment in elderly patients with hip fracture: validating a simple bedside test

AIMS

1. To assess the prevalence of visual impairment in those patients who sustain proximal hip fracture after a simple fall. 2. To test the validity of a simple screening test to identify patients with visual impairment.

METHODS

Patients on the orthopaedic rehabilitation ward recuperating from proximal hip fracture were recruited. The nurse screener and examining Ophthalmologist independently assessed the patients' distance visual acuity and visual field to confrontation. In addition, the nurse screener assessed for the presence of cataract in the red reflex and the examining Ophthalmologist performed a dilated slit-lamp examination. On completion of the examination, the Ophthalmologist documented the cause(s) of any visual impairment found.

RESULTS

A total of 89 patients were assessed. In all, 29 patients (33%) could be classified as visually impaired using the United States criteria and 52 patients (58%) had a distance visual acuity of 6/18 or worse in at least one eye. The test reliably identified those patients with visual impairment (sensitivity 94% (+/-5%), specificity 92% (+/-6%)), but was less reliable at identifying those patients with potentially remedial visual impairment (sensitivity 70% (+/-10%), specificity 92% (+/-6%)).

CONCLUSION

The level of visual impairment in this group of patients is high and screening for visual impairment in the elderly with a history of falls is justified. We have demonstrated that a suitably trained member of the rehabilitation team can identify over 94% of those patients with impaired vision. We believe this simple test should now be incorporated into the assessment of all patients requiring rehabilitation after a proximal hip fracture.

Hip fractures in patients with inflammatory bowel disease and their relationship to corticosteroid use: a population based cohort study

BACKGROUND

Inflammatory bowel disease (IBD) is known to be associated with reduced bone density but the extent to which this results in an increased risk of fracture and the contribution of corticosteroid therapy are unclear. We have conducted a large cohort study to address these issues.

METHODS

We selected subjects within the General Practice Research Database (GPRD) with a diagnosis of IBD and up to five matched controls for each patient. We derived dates of recorded hip fractures and also information on smoking, use of corticosteroids, and a number of other drugs. We calculated the absolute risk of fracture and the relative risk as a hazard ratio corrected for available confounders by Cox regression.

RESULTS

Seventy two hip fractures were recorded in 16 550 IBD cases and 223 in 82 917 controls. Cox modelling gave an unadjusted relative risk of hip fracture of 1.62 (95% confidence interval (CI) 1.24-2.11) for all IBD, 1.49 (1.04-2.15) for ulcerative colitis (UC) and 2.08 (1.36-3.18) for Crohn's disease (CD). Multivariate modelling showed that both current and cumulative use of corticosteroids and use of opioid analgesics confounded this relationship. After adjusting for confounding, the relative risk was 1.41 (0.94-2.11) for UC and 1.68 (1.01-2.78) for CD.

CONCLUSION

The risk of hip fracture is increased approximately 60% in IBD patients. Corticosteroid use is a contributor to this, both in the long term as previously recognised and also in an acute reversible manner. The majority of hip fracture risk in IBD patients however cannot be attributed to steroid use.

Does influenza vaccination increase consultations, corticosteroid prescriptions, or exacerbations in subjects with asthma or chronic obstructive pulmonary disease?

BACKGROUND

Concern over the safety of influenza vaccination in individuals with obstructive airways disease has contributed to suboptimal rates of vaccine uptake in this group. We investigated the safety of influenza vaccine in older people with asthma or chronic obstructive pulmonary disease (COPD) in a cohort from the UK General Practice Research Database (GPRD).

METHODS

A population based cohort study of 12,000 individuals with asthma or COPD from 432 general practices was conducted. Incidence rate ratios (IRR) were calculated for asthma or COPD diagnoses, prescriptions for oral corticosteroids, and acute exacerbations on the day of vaccination and on days 1-2 and 3-14 after vaccination compared with other time periods in the influenza season.

RESULTS

The IRRs for asthma or COPD diagnoses and oral corticosteroid prescriptions were increased on the day of vaccination (for example, the IRR for oral corticosteroid prescriptions for subjects with asthma during the 1992-3 influenza season was 8.24 (95% confidence interval 5.54 to 12.26)). However, there was no consistent increase in the IRR of any of the outcomes on days 1-2 or 3-14 after vaccination, and most of these IRRs were close to 1. Rates of exacerbation were low and showed no consistent statistically significant increase during any risk periods.

CONCLUSIONS

Older people with asthma or COPD commonly have diagnoses recorded or prescriptions for oral corticosteroids given on the day of influenza vaccination, but there is no increased risk of adverse acute outcomes in the first 2 weeks after vaccination. Our findings strongly suggest that influenza vaccination is safe in this population.

Seroprevalence, correlates, and characteristics of undetected coeliac disease in England

OBJECTIVE

To examine the seroprevalence, correlates, and characteristics of undetected coeliac disease in a large adult population sample in Cambridge, UK.

METHODS

The Cambridge General Practice Health Study invited individuals from 12 general practices, aged 45-76 years, to attend for a health survey that included a bone density measurement, between 1990 and 1995. A total of 7550 participants' serum samples were tested for antiendomysial antibody (EMA). Seroprevalence of undetected coeliac disease was based on EMA positivity. Differences between EMA positive and negative participants of various physiological correlates and reported characteristics were estimated by multivariate logistic and linear regression and adjusted for age, sex, social class, and smoking behaviour.

RESULTS

The seroprevalence of undetected coeliac disease in this general population sample aged 45-76 was 1.2% (95% confidence interval (CI) 0.9-1.4). EMA positive participants (n=87) were on average slightly lighter by 2.2 kg (p=0.08), were more likely to have reported their general health as being "good or excellent" (odds ratio (OR) 1.76 (95% CI 0.90-3.46)), and were less likely to report being a current smoker (OR for current versus never 0.36 (95% CI 0.14-0.90)) than EMA negative participants. EMA positivity was associated with an 8% reduction in mean serum cholesterol (0.5 mmol/l; p<0.01) and reductions in mean haemoglobin (0.3 g/dl; p<0.01), total protein (1.0 g/l; p<0.05), and corrected serum calcium (0.02 mmol/l; p<0.05). There was an increased risk of osteoporosis in EMA positive participants (OR 3.1 (95% CI 1.3-7.2)) and of mild anaemia (OR 4.6 (95% CI 2.5-8.2)) compared with EMA negative participants.

CONCLUSIONS

Undetected coeliac disease is likely to affect approximately 1% of the population of England aged 45-76 years, a value similar to several other countries. Those affected report "better health" but they do have an increased risk of osteoporosis and mild anaemia. In contrast, they have a favourable cardiovascular risk profile that may afford protection from ischaemic heart disease and stroke.

Quantitation of human immunodeficiency virus type 1 in breast milk

The distribution and stability of human immunodeficiency virus type 1 (HIV-1) in breast milk (BM) components remain largely unknown. Inhibitory effects, if any, of BM on HIV RNA and DNA PCR amplification are poorly understood. We have addressed these issues by using virus-spiked BM samples from HIV-negative women. BM samples from HIV-negative women were spiked with HIV-1 virions or cells containing a single integrated copy of HIV DNA (8E5/LAV). After incubation under different experimental conditions, viral RNA was detected by the Roche Amplicor UltraSensitive assay in whole-milk, skim milk, and lipid fractions. We found excellent correlation between HIV-1 input copy and recovery in whole milk (r = 0.965, P < 0.0001), skim milk (r = 0.972, P < 0.0001), and the lipid fraction (r = 0.905, P < 0.001). PCR inhibition was observed in less than 10% of the spiked samples. Similar levels of inhibition were noted in BM samples collected from HIV-infected women. HIV proviral DNA was detected in BM samples using real-time PCR (linear correlation between the threshold cycle versus log DNA copy number, >0.982). The effects of incubation duration and temperature and repeated freeze-thaw cycles on HIV RNA recovery were analyzed. HIV RNA levels were remarkably stable in whole milk after three freeze-thaw cycles and for up to 30 h at room temperature. Our findings improve the understanding of the dynamics of HIV detection in BM and the conditions for BM sample collection, storage, and processing.

Fracture experience of patients with coeliac disease: a population based survey

BACKGROUND

While coeliac disease is now recognised as being associated with both osteoporosis and osteomalacia, the size of any increase in the risk of fracture in patients with coeliac disease compared with the general population has not been quantified.

AIM

To examine the fracture experience of adults with coeliac disease compared with the general population.

SUBJECTS

Patients with coeliac disease diagnosed in adulthood and born before 1950, selected from two large population based disease registers, and age and sex frequency matched controls identified from local general practitioner lists.

METHODS

A four page lifestyle and general health questionnaire which included specific questions about fracture experience.

RESULTS

Analysis was performed on 244 patients with coeliac disease and 161 controls, giving response rates of 89% and 72%, respectively. Eighty two (35%) coeliac patients and 53 (33%) controls reported ever having sustained one or more fractures, giving an age and sex adjusted odds ratio of 1.05 (95% confidence interval (CI) 0.68-1.62). The most common fracture site reported was the forearm or wrist, with an adjusted odds ratio of 1.21 (95% CI 0.66-2.25) for patients with coeliac disease having had a forearm or wrist fracture. Low trauma fractures were reported by 37 patients with coeliac disease (15.7%) and by 21 controls (13.8%), with an adjusted odds ratio of 1.16 (95% CI 0.65-2.10). The risk of low trauma fracture was slightly higher in coeliac men than women (odds ratio 1.28 compared with 1.12), but this difference was not statistically significant (p=0.84). After adjustment for age, sex, body mass index, and smoking status, patients with coeliac disease reported 13% more low trauma fractures than controls (odds ratio 1.13, 95% CI 0.60-2.12). There was no difference in low trauma fracture risk before and after diagnosis of coeliac disease.

CONCLUSION

No overall increased fracture risk in patients with coeliac disease was observed. Although severe osteoporosis may develop in a subset of patients, as a whole patients with coeliac disease do not represent a population at particularly high risk of osteoporotic fracture and thus targeting them for osteoporosis screening and treatment is not justified.

IgA-antitissue transglutaminase: validation of a commercial assay for diagnosing coeliac disease

We have evaluated a commercial assay for serum IgA class antibodies to tissue transglutaminase, the enzyme identified as the major endomysial autoantigen in coeliac disease (CD). Sera were available from 130 adults diagnosed with CD in Southern Derbyshire between 01 01 97 and 31 12 99. Sera from 100 patients without villous atrophy on small intestinal biopsy were controls. The ability of the assay to detect abnormally low total IgA levels was assessed using sera from 18 subjects with IgA deficiency. Sensitivity and specificity of this IgA-anti tissue transglutaminase (tTGA) assay (86.2%, 91.0%) were inferior to endomysial antibody (EMA; 93.8%, 100%). tTGA has significantly higher sensitivity than IgA-antigliadin (76.2%). tTGA was appropriately undetectable (<0.03 U/mL) in 17 of 18 subjects with selective IgA deficiency. The high likelihood ratio (35) for tTGA at levels >9.0 U/mL and methodological advantages over EMA suggest that tTGA could be used as a first line diagnostic test for CD. At tTGA levels of 4-9 U/mL, use of EMA as a second line test would improve specificity.

Treatments for gestational diabetes and impaired glucose tolerance in pregnancy

BACKGROUND

Gestational diabetes and impaired glucose tolerance (IGT) in pregnancy affects between 3 and 6% of all pregnancies and both have been associated with pregnancy complications. A lack of conclusive evidence has led clinicians to equate the risk of adverse perinatal outcome with pre-existing diabetes. Consequently, women are often intensively managed with increased obstetric monitoring, dietary regulation, and in some cases insulin therapy. However, there has been no sound evidence base to support intensive treatment. The key issue for clinicians and consumers is whether treatment of gestational diabetes and IGT will improve perinatal outcome.

OBJECTIVES

The objective of this review was to compare alternative policies of care for women with gestational diabetes and IGT in pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (12 September 2002) and the bibliographies of relevant papers. The Cochrane Central Register of Controlled Trials was also searched (The Cochrane Library, Issue 3, 2002).

SELECTION CRITERIA

Randomised controlled trials comparing alternative management strategies for women with gestational diabetes and IGT in pregnancy.

DATA COLLECTION AND ANALYSIS

Quality was assessed according to the criteria defined by the Cochrane Reviewers' Handbook. Data were extracted and checked independently by two reviewers. Any disagreements were resolved through discussion with the third reviewer.

MAIN RESULTS

Three studies with a total of 223 women were included. All three included studies involved women with IGT. No trials reporting treatments for gestational diabetes met the criteria. There are insufficient data for any reliable conclusions about the effect of treatments for IGT on perinatal outcome. The difference in abdominal operative delivery rates is not statistically significant (relative risk (RR) 0.86, 95% confidence interval 0.51 to 1.45) and the effect on special care baby unit admission is also not significant (RR 0.49, 95% confidence interval (CI) 0.19 to 1.24). Reduction in birthweight greater than 90th centile (RR 0.55, 95% CI 0.19 to 1.61) was not found to be significant. This review suggests that an interventionist policy of treatment may be associated with a reduced risk of neonatal hypoglycaemia (RR 0.25, 95% CI 0.07 to 0.86). No other statistically significant differences were detected. A number of outcomes are only reported by one study resulting in a small sample and wide confidence intervals.

REVIEWER'S CONCLUSIONS

There are insufficient data for any reliable conclusions about the effects of treatments for impaired glucose tolerance on perinatal outcome.

Implantable, polymeric systems for modulated drug delivery

The ability to deliver therapeutic agents to a patient in a pulsatile or staggered release profile has been a major goal in drug delivery research over the last two decades. This review will cover methods that have been developed to control drug delivery profiles with implantable polymeric systems. Externally and internally controlled systems will be discussed, spanning a range of technologies that include pre-programmed systems, as well as systems that are sensitive to modulated enzymatic or hydrolytic degradation, pH, magnetic fields, ultrasound, electric fields, temperature, light and mechanical stimulation. Implantable systems have the potential to improve the quality of life for patients undergoing therapy with a variable dosing regime by eliminating the need for multiple intravenous injections. Ideally, these systems would also result in increased patient compliance with a given therapy due to the relative ease of self-dosing.

Naphthalene-induced respiratory tract toxicity: metabolic mechanisms of toxicity

The lung, which is in intimate contact with the external environment, is exposed to a number of toxicants both by virtue of its large surface area and because it receives 100% of the cardiac output. Lung diseases are a major disease entity in the U.S. population ranking third in terms of morbidity and mortality. Despite the importance of these diseases, key issues remain to be resolved regarding the interactions of chemicals with lung tissue and the factors that are critical determinants of chemical-induced lung injury. The importance of cytochrome P450 monooxygenase dependent metabolism in chemical-induced lung injury in animal models was established over 25 years ago with the furan, 4-ipomeanol. Since then, the significance of biotransformation and the reasons for the high degree of pulmonary selectivity for a myriad of different chemicals has been well documented, mainly in rodent models. However, with many of these chemicals there are substantial differences in the susceptibility of rats vs. mice. Even within the same species, varied levels of the respiratory tract respond differently. Thus, key pieces of data are still missing when evaluating the applicability of data generated in rodents to primates, and as a result of this, there are substantial uncertainties within the regulatory community with regards to assessing the risks to humans for exposure to some of these chemicals. For example, all of the available data suggest that the levels of cytochrome P450 monooxygenases in rodent lungs are 10-100 times greater than those measured in the lungs of nonhuman primates or in man. At first glance, this suggests that a significant margin of safety exists when evaluating the applicability of rodent studies in the human, but the issues are more complex. The intent of this review is to outline some of the work conducted on the site and species selective toxicity and metabolism of the volatile lung toxic aromatic hydrocarbon, naphthalene. We argue that a complete understanding of the cellular and biochemical mechanisms by which this and other lung toxic compounds generate their effects in rodent models with subsequent measurement of these cellular and biochemical events in primate and human tissues in vitro will provide a far better basis for judging whether the results of studies done in rodent models are applicable to humans.

Long-Term Changes in Soft Tissue Height on the Facial Surface of Dental Implants

The success of osseous healing around dental implants has allowed for an increased emphasis on soft tissue healing and esthetic results. However, there is limited information profiling the long-term healing of the soft tissues following prosthesis placement. The purpose of this study was to assess the long-term changes in the position of the facial soft tissue margins following restoration of a one-stage implant system. One hundred and six one-stage ITI implants were evaluated in 39 patients. Implants were placed in maxillary and mandibular anterior regions. Clinical assessment of the soft tissues on the midfacial aspect of the implants was performed over a 2-year period, at 3 and 6 month intervals, following placement of the final restoration. A total of 63 implants were placed as multiple units in the mandible, 23 as single units in the maxilla, and 20 as multiple units in the maxilla. There were no implant failures over this time period. Overall, on the facial aspect of 61% of the 106 implants there was 1 mm or more of soft tissue recession, whereas 19% of the implants showed 1 mm or more of gain in soft tissue height. There was a significantly (P < 0.01) greater number of implants showing a gain in soft tissue levels in the mandibular implants compared with the maxillary implants. Of the 39 patients assessed, 24 showed a loss and five showed a gain of 1 mm or more of the soft tissue levels around the implants. Overall, there was a significant decrease in the mean levels of tissue height of 0.6 mm within the first 6 months, with relatively little change afterward. However, in evaluating only patients showing a loss in tissue height around one or more implants, the mean loss in tissue height was 1.6 mm after 24 months. These results suggest that the potential for significant changes in soft tissue levels after completion of restorative therapy need to be considered for implant therapy in esthetic areas.

An investigation into the factors affecting patient selection of chronic low back management methods, with particular reference to non-utilization of the complimentary therapies, in the United Kingdom

Chronic low back pain (CLBP) is an increasingly common, persistent and costly problem. There is evidence to suggest that some sufferers benefit more from methods still considered 'complimentary' in the UK, than from the conventional management methods, which continue to be offered as standard care under the British National Health System (NHS). Despite this evidence, relatively few CLBP sufferers in the UK utilize these 'complimentary' therapies. This investigation set out to evaluate what factors affect utilization and asks why people do not use complimentary therapies (CTs) for CLBP, as this has not been asked before. One hundred and fifty subjects completed self-reporting questionnaires, which asked about knowledge, health care beliefs and other possible influencing factors. The three groups comprised 50 CLBP sufferers using both private and National Health Service (NHS) funded outpatient conventional management methods, 50 CLBP sufferers using private CT management methods, and 50 'healthy' non-user subjects. Sixty-four per cent of conventional patients had not used CTs. The most significant barriers to the utilization of CTs appeared to be lack of knowledge and lower socio-economic group (SEG). Gender may affect selection.

Nurse-led direct access endoscopy clinics: the future?

BACKGROUND

Many studies have shown that rectal bleeding is a good indicator of underlying colorectal pathology, and that ost of the lesions in patients presenting with rectal bleeding lie in the left side of the colon [1, 5, 9, 12, 23, 26]. The recent acceptance of the nurse-practitioner by the National Health Service may allow the use of nurse-endoscopists to develop throughout the United Kingdom. This study aimed to audit a unique nurse-led direct-access nurse-endoscopy service with regard to its efficacy and cost effectiveness, and to monitor patient satisfaction and direct referrals from the primary health sector.

METHODS

A nurse-led open-access flexible sigmoidoscopy (OAFS) service for patients reporting fresh rectal bleeding was established at our center in February 1996. A prospective audit of sigmoidoscopic findings and a retrospective analysis of referral patterns from local general practitioners were conducted. A questionnaire survey of both patient and general practitioner satisfaction also was conducted at the same time.

RESULTS

Since February 1996, 706 patients have been referred to our service. Rectal bleeding was by far the most common cause for referral, representing the dominant symptom in 92% of the referrals received. Although 99% of the patients underwent a complete sigmoidoscopic examination, 16% of these examinations were limited because of several factors combined. A cause for bleeding was identified in 91% of the patients, with 24% of them experiencing subsequent significant pathology. Of the patients surveyed, 99% were satisfied with the service provided. The results also show nurse-led OAFS to be a more effective use of financial resources, costing $90 less per patient than general practitioner referrals sent to a consultant for further action.

CONCLUSIONS

Rectal bleeding is a good indicator of underlying colorectal disease. Most of the significant lesions presenting with this symptom are found in the left side of the colon. A nurse-led OAFS is safe, effective, and acceptable to patients. It also is more cost effective than a consultant-led service.

A 10 year prospective followup of patients with rheumatoid arthritis 1986-96

OBJECTIVE

To determine the 10 year outcome of hospital patients with established rheumatoid arthritis (RA) treated with disease modifying drugs (DMARD).

METHODS

All patients with RA of at least a year duration and attending a single clinician were followed prospectively for 10 years. DMARD treatments changed with time but were continued throughout. Measurements of joint tenderness (Ritchie Index), morning stiffness, grip, and disability (Health Assessment Questionnaire, HAQ) and radiographs of hands and feet were documented. A record of joint surgery was maintained. Patients who stopped attending the clinic were traced and an accurate record of deaths was obtained from the National Registry of Deaths. Paired clinical indices were compared where available between 0, 5, and 10 years.

RESULTS

At entry there were 289 patients of variable disease duration. Within 10 years, 71 had died (standardized mortality ratio 1.3) and 92 were alive but unavailable. Median joint tenderness, morning stiffness, grip strength, and hemoglobin were not significantly different at 0, 5, and 10 years. Erythrocyte sedimentation rate (ESR) declined but not significantly. By contrast, HAQ scores and radiographs worsened between 0 and 10 years (p = 0.0004, p = 0.0001, respectively). There was a trend toward lower ESR values and less disability and the lower radiographic scores in those with 10-15 years' disease duration in 1996 compared with those of similar duration in 1986. However, worsening of radiographs occurred in patients with short, medium, and long histories of RA. Correlations between disability, radiographic scores, and joint tenderness were apparent at the start and conclusion of the study. At 10 years, 54 (19%) of the original cohort had undergone at least one large joint replacement. Significantly more women required joint replacement surgery (chi-square 5.44, p = 0.02).

CONCLUSION

Over a 10 year period patients with RA exhibited an excess of deaths and a deterioration of radiographs and function despite regular DMARD treatment and apparent clinical containment. Worsening of radiographs occurred in both relatively early and late disease. There was a steady requirement for surgical large joint replacement with time. This study suggests that in the long term. the effect of DMARD treatments may be less than the expectations derived from short term studies.

Macular hole surgery using silicone oil tamponade

BACKGROUND/AIMS

Most surgeons performing macular hole surgery using long acting gas recommend strict postoperative face down posturing for 10-15 days. Patients with chronic systemic illness such as arthritis may be unable to carry out this postoperative regime. Thus there is a need for alternative techniques that would eliminate such a regime. The authors review a series of patients who underwent macular hole surgery using silicone oil without any postoperative posturing.

METHODS

A retrospective case note review was performed of patients who had undergone macular hole surgery with silicone oil tamponade. The patients were unable to posture due to chronic illness and had stage 2, 3, or 4 full thickness macular holes. Removal of silicone oil performed with or without cataract surgery was arranged 3 months or more after surgery.

RESULTS

10 eyes of 10 patients underwent surgery. Duration of oil tamponade ranged from 3-9 months. Following oil removal the hole was closed in eight eyes (80%), of which only three showed any improvement in visual acuity (38%) even after cataract extraction. All eyes developed cataract to varying degrees and one eye developed raised intraocular pressure which settled after oil removal. A serious complication, endophthalmitis, occurred in one eye following removal of sutures after cataract extraction.

CONCLUSION

The anatomical results (80%) in this series are in keeping with those reported in other studies using gas tamponade. The visual results are disappointing and less rewarding than those obtained after successful surgery using gas tamponade.

Endometritis in postparturient cattle associated with bovine herpesvirus-4 infection: 15 cases

Suppurative, ulcerative endometritis associated with bovine herpesvirus-4 (BHV-4) infection was identified in 15 postparturient dairy cows from 5 separate dairies. Characteristic eosinophilic to amphophilic intranuclear viral inclusion bodies were identified within degenerate endometrial lining epithelium and endothelial cells. Bovine herpesvirus-4 was confirmed as the etiology by a combination of fluorescent antibody assays, viral isolation, heminested PCR, ultrastructural examination of the uterus and inoculated tissue culture cells, and negative-stain electron microscopy of tissue culture supernatant. Viral particles measuring 70-95 nm were demonstrated in uterine epithelial and endothelial cells by electron microscopy. Bacteria including Arcanobacterium pyogenes, Escherichia coli, and an alpha-Streptococcus isolate were isolated from all uteri. Bovine herpesvirus-4-associated endometritis has been previously reported in sporadic cases in Europe but has not been previously reported in the United States. Endometritis associated with BHV-4 appears to be an emerging syndrome in Georgia dairy herds.

Comparison of exercise test scores and physician estimation in determining disease probability

BACKGROUND

The recent American College of Cardiology/American Heart Association exercise testing guidelines provided equations to calculate treadmill scores and recommended their use to improve the predictive accuracy of the standard exercise test. However, if physicians can estimate the probability of coronary artery disease as well as the scores can, there would be no reason to add this complexity to test interpretation. To compare the exercise test scores with physician's estimation of disease probability, we used clinical, exercise test, and coronary angiographic data to compute the recommended scores and print patient summaries and treadmill reports.

OBJECTIVE

To determine whether exercise test scores can be as effective as expert cardiologists in diagnosing coronary disease.

METHODS

Five hundred ninety-nine consecutive male patients without previous myocardial infarction with a mean +/- SD age of 59 +/- 11 years were considered for this analysis. With angiographic disease defined as any coronary lumen occlusion of 50% or more, 58% had disease. The clinical/treadmill test reports were sent to expert cardiologists and to 2 other groups, including randomly selected cardiologists and internists, who classified the patients as having high, low, or intermediate probability of disease and estimated a numerical probability from 0% to 100%.

RESULTS

Forty-five expert cardiologists returned estimates on 336 patients, 37 randomly chosen practicing cardiologists returned estimates on 129 patients, 29 randomly chosen practicing internists returned estimates on 106 patients, 13 academic cardiologists returned estimates on 102 patients, and 27 academic internists returned estimates on 174 patients. When probability estimates were compared, the scores were superior to all physician groups (0.76 area under the receiver operating characteristic curve to 0.70 for experts [P=.046], 0.73 to 0.58 for cardiologists [P=.003], and 0.76 to 0.61 for internists [P=.006]). Using a probability cut point of greater than 70% for abnormal, predictive accuracy was 69% for scores compared with 64% for experts, 63% to 62% for cardiologists, and 70% to 57% for internists.

CONCLUSION

Although most similar to the disease estimates of the presence of clinically significant angiographic coronary artery disease provided by the expert cardiologists, the scores outperformed the nonexpert physicians.

Biosynthesis and insecticidal properties of plant cyclotides: the cyclic knotted proteins from Oldenlandia affinis

Several members of the Rubiaceae and Violaceae families produce a series of cyclotides or macrocyclic peptides of 29-31 amino acids with an embedded cystine knot. We aim to understand the mechanism of synthesis of cyclic peptides in plants and have isolated a cDNA clone that encodes the cyclotide kalata B1 as well as three other clones for related cyclotides from the African plant Oldenlandia affinis. The cDNA clones encode prepropeptides with a 20-aa signal sequence, an N-terminal prosequence of 46-68 amino acids and one, two, or three cyclotide domains separated by regions of about 25 aa. The corresponding cyclotides have been isolated from plant material, indicating that the cyclotide domains are excised and cyclized from all four predicted precursor proteins. The exact processing site is likely to lie on the N-terminal side of the strongly conserved GlyLeuPro or SerLeuPro sequence that flanks both sides of the cyclotide domain. Cyclotides have previously been assigned an antimicrobial function; here we describe a potent inhibitory effect on the growth and development of larvae from the Lepidopteran species Helicoverpa punctigera.

School milk as a vehicle for fluoride in the United Kingdom. An interim report

OBJECTIVE

To consider the feasibility of using school milk as a vehicle to deliver fluoride to children, suffering from high rates of dental disease, in socially deprived districts.

METHOD

The legal aspects of adding fluoride to milk and availability of milk subsidies were updated. The organisational requirements of using school milk as a vehicle for fluoride were investigated and the consultation process established. The uptake of fluoridated milk was monitored and the fluoridated milk was subjected to rigorous quality control. The costs involved in running a scheme were calculated.

OUTCOME

Fluoridated milk can now be called milk with added fluoride and to date the product has attracted subsidies from the European Economic Community and from the Welfare Foods Section in the Department of Health. The demonstration scheme in St. Helens, Merseyside, generated interest from neighbouring health authorities leading to the subsequent expansion of the programme. By working with the dairy, recommendations to improve the quality of school milk have been developed. The main organisations involved in running school based milk fluoridation schemes have been encouraged by the low costs involved.

CONCLUSION

The UK programme has demonstrated that it is feasible to use school milk as a vehicle to deliver fluoride on a community basis. Attention must be given to improving the quality and particularly the temperature control of school milk.