Popularity of less frequent follow up for breast cancer in randomised study: initial findings from the hotline study

OBJECTIVE

To compare the experiences of patients with breast cancer who were conventionally monitored with those in whom routine follow up was restricted to the time of mammography.

DESIGN

Randomisation to conventional schedule of clinic visits or to visits only after mammography. Both cohorts received identical mammography and were invited to telephone for immediate appointments if they detected symptoms.

SETTING

Combined breast clinic, Chelsea and Westminster Hospital.

SUBJECTS

211 eligible outpatients with a history of breast cancer.

MAIN OUTCOME MEASURES

Acceptability of randomisation, interim use of telephone and general practitioner, satisfaction with allocation to follow up.

RESULTS

Of 211 eligible patients, 196 (93%) opted for randomisation in the study. Of these, 55 were under 50 years, 78 were diagnosed fewer than five years before, 90 had stage T2-4 tumours, and 71 had involved axillary nodes. Patients who did not participate were more likely to be under 50 years, to be two to five years after diagnosis, and to have had aggressive primary disease. Twice as many patients in both groups expressed a preference for reducing rather than increasing follow up. No increased use of local practitioner services or telephone triage was apparent in the cohort randomised to less frequent follow up by specialists.

CONCLUSIONS

Reducing the frequency of routine follow up has so far proved popular among patients with breast cancer at standard risk in this cohort. A multicentre study is needed to determine the effectiveness and cost-effectiveness of routine follow up with respect to disease outcomes.

Adapting Eimeria tenella to grow in primary chicken kidney cells following repeated passages between cell culture and chickens

The present study was undertaken to adapt a field isolate (F0) of Eimeria tenella to grow in primary chicken kidney cells (PCKCs) by selecting for characteristics of the parasite rather than modifying the culture and/or environmental conditions. Fourteen generations (F1 to F14) of E. tenella were produced following repeated passages between PCKCs and chickens. Although F1 yielded only a 28% increase in oocysts, in PCKCs compared with F0, F2 to F5 produced from 259% to 277% more oocysts, respectively. There was no significant increase in the percentage of oocysts produced in PCKCs by F6 to F14 compared with F5. Generations F1 to F14 demonstrated a greater propensity for multiple infections within the same host cell than did F0. For example, it was not uncommon to observe two, three, and occasionally four oocysts within a single PCKC. Chickens inoculated with F0 oocysts generally experienced greater pathogenesis by day 7 postinoculation than chickens inoculated with F14 oocysts as measured by decreased body weights, increased cecal lesions, and a higher mortality rate.

Evaluation of a modular endovascular bifurcation prosthesis in a canine aortic aneurysm model

PURPOSE

The study evaluated the deployment and healing of a novel self-expanding modular bifurcation endovascular prosthesis in a canine abdominal aortic aneurysm model. The endoluminal prosthesis consists of self-expanding nitinol stents lined by a synthetic prosthesis. One component of the device is a bifurcated body with a 12- to 14-mm diameter aortic segment and an integral 7- to 8-mm diameter iliac limb. The bifurcated body also has a stent-reinforced opening (pant-leg) for subsequent insertion of a contralateral 7- to 8-mm diameter iliac limb component.

METHODS

Seventeen bifurcated prosthesis were placed; 7 were inserted through the left common carotid artery and 10 from the femoral arteries. With either route of access the 16F or 17F aortoiliac limb and the 13F iliac limb delivery catheters enabled easy passage and secure positioning of the bifurcated prostheses. Predeployment and postdeployment inspection of the dimensions and continuity of the aortoiliac prosthetic components were evaluated by cinefluoroscopy and intravascular ultrasonography (IVUS).

RESULTS

After deployment was done, interval patency was assessed with angiography, IVUS, and contrast-enhanced computed tomography with the prostheses removed for analysis at 1 week (n = 4), 1 month (n = 3), 3 months (n = 4), and 6 months (n = 6). Five of the first seven implanted prostheses had occlusion of segments of the device. In two dogs the bifurcated body and both legs were occluded. In the other three the nonoccluded leg and bifurcation body were fully patent. In the first seven animals IVUS at implantation showed compression of an iliac leg by the orifice of the contralateral iliac component. After concentric fixation of the flow divider was performed, only one additional iliac limb occlusion occurred in the next 10 animals. Cinefluoroscopy, computed tomography, IVUS imaging, and histologic analysis of retrieved specimens demonstrated healing of the aortoiliac prostheses without evidence of perigraft leaks.

CONCLUSIONS

This feasibility study demonstrates the ability to deploy and maintain acceptable patency of a self-expanding endoluminal, modular bifurcation prosthesis in a canine aortic model. Clinical evaluation of the device is planned for the near future.

Synthesis and characterization of insulin-like growth factor-binding protein (IGFBP)-7. Recombinant human mac25 protein specifically binds IGF-I and -II

The mac25 cDNA was originally cloned from leptomeningial cells and subsequently reisolated through differential display as a sequence preferentially expressed in senescent human mammary epithelial cells. The deduced amino acid sequence of the human mac25 propeptide shares a 20-25% identity to human insulin-like growth factor-binding proteins (IGFBPs), suggesting that mac25 could be another member of the IGFBP family. In the present study, we have generated recombinant human mac25 (rh-mac25) in a baculovirus expression system and assessed its affinity for IGFs and have evaluated the pattern of expression of the mac25 gene in human tissues. Binding of 125I-IGF-I and 125I-IGF-II to rh-mac25 was demonstrated by Western ligand blotting after nondenaturing polyacrylamide gel electrophoresis and by affinity cross-linking with as little as 2 nM rh-mac25. Specificity of rh-mac25 binding to 125I-IGFs was demonstrated by competition for rh-mac25 binding with unlabeled IGFs, but not with [QAYLL]IGF-II analog, which has 100-fold less affinity for IGFBPs. In comparison with IGFBP-3, rh-mac25 has at least a 5-6-fold lower affinity for IGF-I and 20-25-fold lower affinity for IGF-II. mac25 mRNA was detectable in a wide range of normal human tissues, with decreased expression in breast, prostate, colon, and lung cancer cell lines. In conclusion, mac25 specifically binds IGFs and constitutes a new member of the IGFBP family, IGFBP-7. Its wider distribution in normal tissue and lower expression in several cancer cells indicate that IGFBP-7 may function as a growth-suppressing factor, as well as an IGF-binding protein.

Mechanical strain increases smooth muscle and decreases nonmuscle myosin expression in rat vascular smooth muscle cells

The effect of cyclic (1-Hz) mechanical strain on expression of myosin heavy chain isoforms was examined in neonatal rat vascular smooth muscle cells cultured on silicone elastomer plates. Myosin heavy chain isoforms were identified by immunoblot using antibodies recognizing (1) smooth muscle myosin heavy chain isoforms SM-1 and SM-2, (2) SM-1 exclusively, and (3) nonmuscle myosin heavy chains A and B. In response to 36 to 72 hours of strain, SM-1 and SM-2 increased by fourfold to sixfold, whereas nonmuscle myosin A decreased to 30% of control. Nonmuscle myosin B was unaffected by strain. SM-1 mRNA increased by twofold to threefold after 12 hours of strain but decreased toward control levels thereafter. SM-2 mRNA was only barely detectable. Nonmuscle myosin A mRNA decreased to 50% of control after 3 hours of strain and then returned to the control level. Since these cells secrete platelet-derived growth factor (PDGF) in response to strain, we assessed the effects of PDGF on myosin isoform expression. Exogenous PDGF (10 ng/mL) decreased SM-1 expression by 35% and increased nonmuscle myosin expression twofold, opposite the effect of strain. In cells exposed to strain with neutralizing antibodies to PDGF-AB, the strain-induced increase in SM-1 was enhanced 10-fold, and nonmuscle myosin A was reduced to 40% of control. Finally, the effect of extracellular matrix on transduction of the strain signal was studied. Forty-eight hours of cyclic strain increased SM-1 by twofold in cells cultured on collagen type 1 and threefold in cells cultured on laminin. In fibronectin-cultured cells, strain elicited no increase in SM-1. Thus, mechanical strain, sensed through specific interactions with the matrix, can alter myosin isoform expression toward that found in a more differentiated state.

Comparison of the deployment and healing of thin-walled expanded PTFE stented grafts and covered stents

This study evaluated the deployment and short-term healing of thin-walled expanded polytetrafluoroethylene (ePTFE) stented grafts and covered stents as endoluminal prostheses in normal canine aortas and in an abdominal aortic aneurysm (AAA) model. Stented grafts consisted of a 7 cm length of 3 mm internal diameter ePTFE graft (Impra, Inc., Tempe, Ariz.) with two P-188 Palmaz stents (Johnson & Johnson Interventional Systems, Warren, N.J.) deployed along the inner surface of the ends of the graft to secure the prosthesis to the arterial wall. Covered stents were fabricated by placing a 3.7 cm length of 3 mm internal diameter thin-walled ePTFE graft over a P-394 Palmaz stent. Four covered stents and four stented graft prostheses (two of each prototype in the normal canine aorta and AAA model) were implanted in eight animals. One prosthesis of each type in each model was removed at 30 days and one at 60 days. Prior to removal, prostheses were evaluated by CT scan, arteriography, and intravascular ultrasound imaging with values compared to those obtained when the prostheses were deployed. Gross inspection and microscopic evaluation were performed at scheduled explantation. In general, the stented grafts were more difficult to accurately deploy. Healing and maintenance of long-term patency without significant luminal obstruction or occlusion occurred in only one 30-day sample in a normal canine aorta. The 30-day stented graft specimen that had been implanted in an AAA and required the addition of a covered stent to seal a maldeployment of the distal segment was also patent. The 60-day stented graft in the normal canine aorta was occluded with narrowing of the graft between the stents. The 60-day stented graft in the AAA was patent with one central fold and thrombus occupying approximately 20% to 30% of the lumen at this site. In contrast, the covered stent devices were less difficult to accurately deploy. All of the covered stent devices were patent with well-incorporated surfaces. Deployment of covered stents was more accurate and less complicated compared to stented grafts. All patent endoluminal prostheses and stent surfaces were well incorporated into aortic tissues. Problems with graft narrowing, folding, and subsequent thrombosis occurred in the unstented segments of the stented grafts. These preliminary findings support the further development and use of completely supported (stented) devices as endoluminal prostheses.

Fiber-coupler-based measurement of lenslet focal lengths

In a technique reminiscent of the classic autocollimation method, we demonstrate that focal lengths of micro-optic lenses may be measured precisely by the use of a mirror and a 2 × 1 fiber coupler.

Increasing the yield of Eimeria tenella oocysts in primary chicken kidney cells

The present study was undertaken to increase the yield of Eimeria tenella oocysts in primary chicken kidney cells (PCKCs) using a comparatively inexpensive cell-culture system. PCKCs growing on coverslips positioned on the bottoms of individual wells in 24-well tissue-culture plates were infected with sporozoites of E. tenella. The effects of changing the culture medium (RPMI 1640), medium pH, serum type, and serum concentration in the wells were determined by counting newly produced oocysts at 7 days postinoculation. There were significantly more (P < 0.01) oocysts produced when the medium was supplemented with 10% fetal bovine serum (FBS) and changed either daily or every other day compared with not changing the medium. When the same medium was changed daily, significantly more (P < 0.05) oocysts were produced at pH 7.4 than at pH 8.0 but not at pH 6.0. If the medium was changed daily, significantly more (P < 0.05) oocysts were produced when medium was supplemented with 10% FBS only rather than 5% and 10% chicken serum. The cell-culture system described in this study offers a convenient and efficient method for investigating the biological, biochemical, and immunological relationships between E. tenella and the host cell.

[Changes in the liver biopsies of pediatric cancer patients who carry the B virus]

Liver biopsies from 27 patients with malignant diseases and virus B carriers state were studied. The age of the patients ranged from 2 to 14 years. ELISA tests for virus B hepatitis were performed in all patients. Three of them resulted HBV positive at admission, whereas 24 became positive after anti-tumoral treatment onset. One patient was also virus C positive. Morphological disorders findings comprises: symptomless acute hepatitis in 7 patients (including the B-C carrier), minimal hepatocytes damage was found in 17 patients as the result of their carriers state and where also certain drug-induced hepatotoxic effect might be present. In this group there were also 7 biopsies with minimal portal region damage. Three biopsies were reported as normal liver tissue. This results confirmed the significance of the study of serological hepatitis viral test and hepatic biopsy in high risk group patients, where it is also necessary the vaccination against HBV before treatment onset.

Getting the FAccts (Foundation for Accountability) straight

Purchasers and consumers are taking the lead in monitoring health care quality through the new Foundation for Accountability. The aim is to consolidate, not proliferate, the quality criteria to which hospitals will have to respond in the future.

Mechanical strain of rat vascular smooth muscle cells is sensed by specific extracellular matrix/integrin interactions

Cyclic mechanical strain (1 Hz) causes a mitogenic response in neonatal rat vascular smooth muscle cells due to production and secretion of PDGF. In this study, the mechanism for sensing mechanical strain was investigated. Silicone elastomer strain plates were coated at varying densities with elastin, laminin, type I collagen, fibronectin, or vitronectin. Strain was applied by cyclic application of a vacuum under the dishes. Cells adhered, spread, and proliferated on each matrix protein, but the mitogenic response to strain was matrix dependent. Strain increased DNA synthesis in cells on collagen, fibronectin, or vitronectin, but not in cells on elastin or laminin. When strain was applied on matrices containing both laminin and vitronectin, the mitogenic response to strain depended upon the vitronectin content of the matrix. Fibronectin, in soluble form (0-50 micrograms/ml), and the integrin binding peptide GRGDTP (100 micrograms/ml) both blocked the mitogenic response to mechanical strain in cells grown on immobilized collagen. Neither soluble laminin nor the inactive peptide GRGESP blocked the response to strain. GRGDTP did not alter the mitogenic response to exogenous PDGF or alpha-thrombin but did prevent the secretion of PDGF in response to strain. Furthermore, GRGDTP, but not GRGESP, prevented strain-induced expression of a PDGF-A chain promoter 890 bp-chloramphenicol acetyltransferase construct that was transiently transfected into vascular smooth muscle cells. Finally, the response to strain was abrogated by antibodies to both beta 3 and alpha v beta 5 integrins but not by an antibody to beta 1 integrins. Thus interaction between integrins and specific matrix proteins is responsible for sensing mechanical strain in vascular smooth muscle cells.

Basic and acidic fibroblast growth factor increase prolactin mRNA in a dose-dependent and specific manner in GH3 cells

In the present report we have studied the effects of acidic and basic molecular forms of the fibroblast growth factor (aFGF, bFGF) on prolactin (PRL) mRNA production and PRL secretion in GH3 cells, a rat pituitary cell line, and their interactions with 17 beta-estradiol (beta E2). To meet this purpose we measured mRNA levels in the cells by both Northern blot and dot blot hybridization analysis, and rPRL immunoreactivity in the culture medium by specific RIA. We observed a marked increase in PRL mRNA levels following 24 h incubation with both basic and acidic FGF. This effect was dose-dependent, with maximal responses ranging between 300 and 600% above the control values. bFGF appeared to be much more potent than aFGF (10-50 times), considering the ED50 of the dose-response curves. Prior incubation with beta E2 (10(-8) M) produced an enhancement in the responses to low doses of bFGF and aFGF, but not to high doses, as revealed by dot-hybridization analysis. Northern blot analysis showed also that both aFGF and bFGF, may have a partially additive effect with beta E2, upon the mature form (1 kb) of rPRL mRNA in GH3 cells. Considering that bFGF is present at high levels in the pituitary, our results suggest that FGF could be a physiological regulatory factor for prolactin production and secretion.

Use of patient-controlled analgesia with alfentanil for extracorporeal shock wave lithotripsy

STUDY OBJECTIVE

To compare the efficacy of patient-controlled analgesia (PCA) to physician-controlled analgesia in patients undergoing extracorporeal shock wave lithotripsy (ESWL).

DESIGN

Prospective, randomized trial.

SETTING

New Jersey Kidney Stone Treatment Center at Robert Wood Johnson University Hospital, New Brunswick, NJ.

PATIENTS

62 ASA I, II, and III patients undergoing ESWL.

INTERVENTIONS

The control group (n = 29) received physician-controlled analgesia with continuous infusions (0.75 mcg/kg/min) and intermittent boluses (5 mcg/kg) of alfentanil. PCA patients (n = 33) initially received alfentanil 0.5 mcg/kg followed by a continuous background infusion (0.2 to 0.5 mcg/kg/min) and self-administered alfentanil (3 to 5 mcg/kg) with a 5-minute lockout period. Bolus doses and infusion rates were determined by patient comfort and cardiorespiratory response to alfentanil.

MEASUREMENTS AND MAIN RESULTS

Prior to the procedure, the patients completed two questionnaires (State-Trait Anxiety Inventory and Multidimensional Health Locus of Control Scales). During ESWL, blood pressure, heart rate, respiratory rate, oxygen saturation, end-tidal CO2, and pain and sedation levels were measured at 0, 800, 1,600, 2,400, and 3,000 shock waves. The total doses of alfentanil administered were calculated. PCA patients received 31% less alfentanil than control group patients (p < 0.0001). Patients with more preoperative anxiety required larger doses of alfentanil (p < 0.05). The pain level was slightly higher in the patients receiving PCA (p > 0.05) but most patients reported either no or only mild pain. Side effects from the therapy, such as nausea and vomiting, were either not present or were mild in both groups, with one patient (3% to 4%) in each group reporting mild nausea. Both patients and urologists were very satisfied with the pain management in both groups.

CONCLUSIONS

PCA is a useful alternative to physician-controlled analgesia during ESWL since it provides equivalent pain control while using less alfentanil.

Marginal bleaching of thalli of Rhizocarpon as evidence for acid rain in the Norra Storfjället, Sweden

Recent lichen surveys in the foreland of The Syterbäcken glacier reveal that the crustose lichens, principally species of Rhizocarpon section Rhizocarpon, exhibit marginal bleaching, readily distinguishable from normal pigmented forms. The largest elliptical thallus of Rhizocarpon measured 290 mm maximum diameter on a bedrock outcrop beyond the margin of Little Ice Age moraines in the upper Syterbäcken Valley. Many small and large thalli of Rhizocarpon suffered damage to the periphery of individual thalli. We examine here some of the possible hypotheses explaining these occurrences. Among others, these are bedrock lithology, ice crystal blasting, long-term snowbank cover, ultraviolet exposure and acid rain. While at this time none of the possibilities can be ruled out entirely, acid rain would appear to be at least one of the factors involved. Acid rain, which is known to produce a soil pH as low as 3.3 in the field area, appears to provide a high input of H(+) ions that the lichen algal component cannot withstand. However, the lack of similar effects on associated foliose or fruticose forms raises the possibility that perhaps two or more factors specific to the environment of Rhizocarpon are operating.

Activation of Na+/H+ exchange by platelet-derived growth factor involves phosphatidylinositol 3'-kinase and phospholipase C gamma

The effect of site-specific mutations in the mouse platelet-derived growth factor (PDGF) beta-receptor on activation of the Na+/H+ exchanger was examined in normal murine mammary gland epithelial (NMuMG) and Chinese hamster ovary (CHO) cells. These cells, which do not normally express PDGF receptors, were stably transfected with PDGF beta-receptor cDNA. Intracellular pH and Ca2+ were monitored using fluorescent probes. In both NMuMG and CHO cells expressing wild-type PDGF beta-receptors, PDGF B/B activated the amiloride-sensitive Na+/H+ exchanger. In both cell types, cell alkalinization was reduced by approximately 50% with a receptor mutant Y708F,Y719F which cannot bind phosphatidylinositol (PI) 3'-kinase. An inhibitor of PI 3'-kinase, LY294002, also inhibited alkalinization by 43% in cells with wild-type, but not Y708F,Y719F receptors. PDGF-induced intracellular Ca2+ release was not affected by this mutation. Both alkalinization and Ca2+ release were reduced by nearly 100% with the mutant Y977F,Y989F, which cannot bind phospholipase C gamma (PLC gamma). Y739F, a mutant that fails to bind the GTPase-activating protein did not affect PDGF-induced alkalinization. In protein kinase C (PKC) down-regulated NMuMG cells (wild-type receptor), PDGF no longer activated the Na+/H+ exchanger. In contrast, in PKC down-regulated CHO cells (wild-type receptor), PDGF-induced alkalinization was attenuated by only 37%. This residual activity was unaffected by the Y708F,Y719F mutation, but was completely eliminated by removal of medium Ca2+. These findings indicate that phospholipase C gamma is essential for activation of Na+/H+ exchange. PI 3'-kinase participates in PKC-dependent activation of Na+/H+ exchange by PDGF. In CHO cells, there is a second, Ca(2+)-dependent mechanism for activation of the exchanger.

Phospholipase C gamma activation, phosphotidylinositol hydrolysis, and calcium mobilization are not required for FGF receptor-mediated chemotaxis

Basic fibroblast growth factor (FGF) is a potent angiogenic factor that stimulates several cell types to migrate along a chemotactic gradient. Most chemoattractant receptors appear to share a common mechanism that involves activation of phospholipase C (PLC), hydrolysis of phosphotidylinositol, and mobilization of intracellular calcium. We transfected two different cell lines with either human FGF receptor-1 cDNA or chimeric FGF receptor cDNA. Ligand stimulation induced chemotaxis, activation of PLC gamma, phosphotidylinositol hydrolysis, and calcium mobilization in both wild-type receptor cell lines. No such response was elicited in control cells. Mutation of the two fibroblast growth factor receptors at residue 766, replacing tyrosine with phenylalanine, made the receptors incapable of associating with and activating PLC gamma following ligand stimulation. These mutant receptors also failed to mediate phosphotidylinositol hydrolysis and calcium mobilization. However, cells transfected with the mutant fibroblast growth factor receptors were as chemotactically responsive to the appropriate ligand as were cells transfected with the wild-type receptors. These findings demonstrate that the ability of the fibroblast growth factor receptor to promote chemotaxis is not dependent on increased activation of PLC gamma, increased hydrolysis of phosphotidylinositol, or increased global mobilization of calcium.

Respiratory syncytial virus subgroup B dominance during one winter season between 1987 and 1992 in Vancouver, Canada

A subgroup analysis of 613 specimens submitted to the British Columbia's Children's Hospital from 1987 to 1992 revealed that subgroups A and B of respiratory syncytial virus (RSV) were both circulating in our community, with some predominance for subgroup A during the period from October 1987 to September 1988 (the 1987-88 season) (64%), 1990-91 (60%), and 1991-92 (62%). During 1989-90 subgroup A represented the majority of isolates (80%). Subgroup B predominated during only one season, 1988-89 (94%). No microheterogeneity within subgroups was apparent as judged by the monoclonal antibody reactivity pattern. More male than female children were affected overall, but no sex-related difference between subgroup infections could be detected (P = 0.28). The majority of patients were less than 1 year of age, and no significant association between age and subgroup was detected after stratifying for year (P = 0.64). This is, to our knowledge, the first comprehensive longitudinal RSV subgroup prevalence study from the Pacific Northwest and from Canada.

Secretary of State's POPUMET Inspectorate: the first six years

The first six years work of the Secretary of State for Health's Inspectorate for regulation 4 of the Ionising Radiation (Protection of Persons Undergoing Medical Examination or Treatment) Regulations 1988 is described. The regulations are colloquially known by the acronym POPUMET, and implement European Directive 84/466 EURATOM in Great Britain. This laid down basic measures for the protection of persons undergoing medical examination or treatment involving ionising radiation. The POPUMET regulations are applicable to all health care settings, public or private sector, but exclude research. Regulation 4 is intended to prevent unnecessary or excessive medical exposure to radiation. Of 68 reported incidents, 54 (79%) were relevant to regulation 4, comprising 20 (37%) incidents in radiotherapy, 21 (39%) in radiology, 11 (20%) in nuclear medicine and 2 (4%) in dental radiology. Allowing for the denominator number of NHS departments in England, the greatest frequency of incidents were reported from radiotherapy departments, followed by nuclear medicine and then radiology departments. Of the 54 incidents investigated, 42 (78%) required a site visit; 39 (72%) resulted in advice from the Inspectorate; 13 (24%) required no action following investigation and 2 (4%) were still under investigation as at 31 May 1994. No enforcement notices were issued and there were no prosecutions.