Many factors affect children's health

A health strategy for children which concentrates only on the health sector will not serve our children well.

Infection in surgical patients: effects on mortality, hospitalization, and postdischarge care

In-hospital mortality, length of stay (LOS), and level of postdischarge care in infected and noninfected surgical patients were studied. An analysis was conducted of a database that included diagnostic, procedure, and drug data collected when surgical patients were discharged from the hospital. Hospitals consisted of 90 nongovernment, nonspecialty, teaching, and nonteaching acute care hospitals of more than 100 beds. Patients in the database included 288,906 patients of all ages hospitalized between July and September 1994. Patients selected of those who had undergone procedures likely to pose a moderate to high risk of infection. Of the 288,906 patients, 12,384 had undergone a moderate- to high-risk procedure; of these, 1,479 (11.9%) had had an infection during their hospitalization. Infection rates ranged from 1.9% to 25.4%, depending on the procedure. The in-hospital mortality rate in infected patients was 14.5%, versus 1.8% for noninfected patients. Similarly, LOS in infected patients (median, 14 days) was substantially greater than in noninfected patients (4 days). About 24% of infected patients required additional professional care after discharge, compared with 7% of noninfected patients. Infection occurs in a substantial portion of surgical patients and is associated with a higher death rate, longer hospitalization, and more intense postdischarge care.

Managerial partnerships. The wave of the future?

Although managerial partnerships are becoming more common in healthcare organizations, very little is available in the literature regarding a practical, concrete methodology for ensuring success of the relationship. The authors explore the nature of managerial partnerships and the perils and pitfalls of forming these relationships. Experiences from successful and failing partnerships will be used to identify the essential elements of healthy partnerships. Key steps and principles for creating a successful partnership are identified.

Colorectal and extracolonic cancer variations in MLH1/MSH2 hereditary nonpolyposis colorectal cancer kindreds and the general population

PURPOSE

This clinical case review aimed to identify phenotypic variations in colorectal and extracolonic cancer expression between hereditary nonpolyposis colorectal cancer (HNPCC) families with MLH1 and MSH2 germline mutations and the general population.

METHODS

Colorectal cancer onset and site distribution were compared among 67 members of MLH1 kindreds, 45 members of MSH2 kindreds, and 1,189 patients from the general population. Synchronous and metachronous cancer rates, tumor stage, extracolonic cancer incidence, and survival were also compared.

RESULTS

Mean ages of colorectal cancer onset were 44, 46, and 69 years for MLH1, MSH2, and the general population, respectively (P < 0.001). More proximal and fewer distal colon cancers were noted in HNPCC than the general population (P < 0.001, P = 0.04). Site distribution showed disparity of rectal cancers (8 percent MLH1 vs. 28 percent MSH2; P = 0.01) based on genotypes. Overall, synchronous colorectal cancer rates were 7.4, 6.7, and 2.4 percent for MLH1, MSH2, and the general population, respectively (P = 0.016). Annual metachronous colorectal cancer rates were 2.1, 1.7, and 0.33 percent for MLH1, MSH2, and the general population, respectively (P = 0.041). Colorectal cancer stage presentation was lower in HNPCC than the general population (P = 0.0028). Extracolonic cancers were noted in 33 percent of MSH2 patients, compared with 12 percent of MLH1 patients and 7.3 percent of the general population with colorectal cancers (P < 0.001). Combined MLH1 and MSH2 ten-year survival was 68.7 percent compared with 47.8 percent for the general population (P = 0.009 stage stratified, hazard ratio 0.57).

CONCLUSION

The presence of rectal cancer should not preclude the diagnosis of HNPCC, because the incidence of rectal cancer in MSH2 was comparable with that in the general population. Phenotypic variations, including the preponderance of extracolonic cancers in MSH2 patients, did not result in survival differences between genotypic subgroups. These phenotypic features of HNPCC genotypes may have clinical significance in the design of specific screening, surveillance, and follow-up for affected individuals.

The pathophysiological role of estrogen receptor variants in human breast cancer

The accumulated evidence supports the expression of estrogen receptor variants at both the mRNA and protein levels. The relative level of expression of some estrogen receptor variant mRNAs and possibly progesterone receptor variant mRNAs is altered during breast tumorigenesis and breast cancer progression. The altered expression of estrogen receptor variants may effect estrogen signal transduction as well as the interpretation of assays where the estimation of estrogen receptor levels is used as a guide to treatment strategies and prognosis.

Somatic hypermutation in autoimmune thyroid disease

Autoimmune thyroid disease is one of the most common autoimmune diseases. There is typically patient antibody (Ab) reactivity to one or more of the antigens thyroglobulin (Tg), thyroid peroxidase (TPO) and the thyroid simulating hormone receptor (TSHr). With the advent of combinatorial library technology, there has been an enormous increase in the number of sequences from Ab to Tg and TPO. The repertoire of both Tg and TPO Ab is restricted and indicates the importance of somatic hypermutation in the development of the high affinity Ab response. However, there are still too few sequences to determine patterns in which the mutation occurs, which residues are introduced during substitution and how individual substitutions affect the affinity of the Ab. Ab to the TSHr are of far greater pathological significance than those to Tg and TPO, but the current repertoire of Ab to the TSHr has yet to include the high affinity IgG Ab characteristic of patient serum Ab. Instructive analysis of the role of somatic hypermutation in the development of TSHr Ab therefore still awaits the isolation of the pathologically active repertoire. Despite this, the Ab response in thyroid autoimmunity remains one of the best characterised of human autoimmune diseases.

Characterization of the Prk1 protein kinase from Schizosaccharomyces pombe

We report the isolation and characterization of a protein kinase from the fission yeast Schizosaccharomyces pombe. The proposed Prk1 protein contains 352 amino acids and has significant homology to the Ume5p kinase (also known as Srb10p, Ssn3p and Are1p) of the budding yeast Saccharomyces cerevisiae, a cyclin-dependent kinase involved in regulating the transcription of a diverse set of genes. Disruption of the prk1 gene increases flocculation but does not appear to have any other significant effect on cell behaviour. This defect can be overcome by expressing the UME5 gene, indicating that Prk1 is the fission yeast homologue of Ume5p.

Health difference in eastern Europe: preliminary findings from the Nowa Huta study

This paper reports the findings of a retrospective study of differential mortality trends among men in a cohort of steelworks employees during the period 1974-1993, a period which encompassed the rise of Solidarity, martial law, and the transition to democracy in Poland. The Nowa Huta study traced vital status for 34,141 individuals and found few systematic differences in death rates among the social groupings it compared. However, there was a significant temporary increase in mortality differentials between skilled and unskilled manual workers, as well as between men of manual worker and peasant farmer origin, in 1981. In addition, differences between manual and non-manual workers opened up after 1991 and reached statistical significance in 1993. This paper considers the extent to which employment at the Nowa Huta steelworks, experienced within a specific and changing political context, may have contributed to the pattern of findings revealed by the study. The paper argues that an adequate account of the East-West health divide should include explicit consideration of qualitative differences in the structuring the social distribution of health.

The value of the Rivermead Behavioural Memory Test (Children's Version) in an epidemiological study of older adults with Down syndrome

The Rivermead Behavioural Memory Test for Children (RBMT-C) was used to assess a population-based sample of 74 people with Down syndrome (DS) aged 30 years and over (range 30-65 years) living in the Cambridge health district. Given the high age-specific risk of Alzheimer-like neuropathology in people with DS, the aim of this study was to determine whether this test provided a suitable measure of memory function in an older population of adults with DS who were at the age of risk for Alzheimer's disease. We also investigated whether there was a significant difference in everyday memory performance between different age, gender and day-centre groups. The level of learning disability in our sample ranged from mild, through severe to profound. Individuals with severe or profound learning disability were virtually untestable on this and other cognitive tests, but for the remaining two-thirds of the group, the RBMT-C could be used to assess memory function. Significant differences in memory function were found between younger (30-44 years) and older (45+ years) participants. Performance also varied between groups (e.g. from different day centres), illustrating the importance of population-based samples when determining the value of such tests. Ongoing longitudinal studies are required to establish the extent to which the RBMT-C is useful in assessing change in retrospective and prospective memory.

Cumulative incidence of colorectal and extracolonic cancers in MLH1 and MSH2 mutation carriers of hereditary nonpolyposis colorectal cancer

The extracolonic tumor spectrum of hereditary nonpolyposis colorectal cancer (HNPCC) includes cancer of the endometrium, ovaries, stomach, biliary tract, and urinary tract. This study was designed to determine the penetrance of colorectal and extracolonic tumors in HNPCC mutation carriers. Forty-nine patients (22 females and 27 males) were identified with an MSH2 germline mutation, and 56 patients (28 females and 28 males) were identified with an MLH1 I mutation. Cumulative incidence by age 60 (lifetime risk) and mean age of cancer diagnosis were compared. The lifetime risk of extracolonic cancers in MSH2 and MLH1 carriers was 48% and 11%, respectively (P = 0.016). Extracolonic cancer risk in MSH2 females and males was 69% and 34%, respectively (P = 0.042). Mean age of extracolonic cancer diagnosis was significantly older for MSH2 males than females (55.4 vs. 39.0, P = 0.013). No difference was observed in colorectal cancer risk between MLH1 and MSH2 carriers (84% vs. 71%). Colorectal cancer risk was 96% in MSH2 males compared to 39% in MSH2 females (P = 0.034). No differences in colorectal and extracolonic cancer risks between MLH1 females and males were identified. The risk of extracolonic cancer by age 60 was greater in MSH2 mutation carriers than in MLH1 carriers. Gender differences in colorectal and extracolonic cancer risk were observed for MSH2 carriers only. These phenotypic features of HNPCC genotypes may have clinical significance in the design of genotype-specific screening, surveillance, and follow-up for affected individuals.

Hirschsprung disease in MEN 2A: increased spectrum of RET exon 10 genotypes and strong genotype-phenotype correlation

The RET proto-oncogene encodes a transmembrane receptor with tyrosine kinase activity. Germline mutations in RET are responsible for a number of inherited diseases. These include the dominantly inherited cancer syndromes multiple endocrine neoplasia types 2A and 2B (MEN 2A and MEN 2B) and familial medullary thyroid carcinoma (FMTC), as well as some cases of familial Hirschsprung disease (HSCR1). RET mutations in HSCR1 have been shown to cause a loss of RET function, while the cancer syndromes result in RET oncogenic activation. Occasionally MEN 2A or FMTC occurs in association with HSCR1, albeit with low penetrance. An initial report linked HSCR1 in MEN 2A solely to the C618R and C620R RET mutations. In this study we have analyzed 44 families with MEN 2A. HSCR1 co-segregated with MEN 2A in seven (16%) of the 44 families. The predisposing RET mutation in all seven families had been previously reported in MEN 2A or FMTC and occurred in exon 10 at codons 609, 618 or 620, resulting in C609Y, C618S, C620R or C620W substitution. MEN 2A families with RET exon 10 Cys mutations had a substantially greater risk of developing HSCR1 than those with the more common RET exon 11 Cys634 or exon 14 c804 mutations (P = 0.0005). These findings suggest that expression of HSCR1 in MEN 2A may be peculiar to RET exon 10 Cys mutations . However, HSCR1 in MEN 2A is not exclusive to C618R or C620R RET mutations and can occur with other exon 10 Cys amino acid substitutions. The strong correlation between disease phenotype and position of the MEN 2A RET mutation suggests that oncogenic activation of RET alone is insufficient to account for co-expression of the diseases.

A PROCESS FOR ESTIMATING GEOLOGICAL RISK OF PETROLEUM EXPLORATION PROSPECTS

The concept of geological risk is critically important in petroleum exploration. It is distinct from both volumetric and commercia I risk. Geological risk is defined as the confidence that a proposed petroleum system is actually working at a particular prospect. Using knowledge-engineering techniques, BHP developed an improved scheme for assessing geological risk. The scheme expands the conventional breakdown of petroleum system elements to about fifty discrete factors, with individual confidence ratings being required for each. The ratings are combined into an overall geological risk using algorithms designed to emulate the typical judgements of experienced explorationists. In practice, application of the scheme also subjects each prospect to an extremely rigorous, detailed and objective review by a technical peer group, which has proved to be a valuable process in its own right. The methodology has improved the accuracy of pre-drill forecasting.

Etiology, natural history, management and molecular genetics of hereditary nonpolyposis colorectal cancer (Lynch syndromes): genetic counseling implications

We estimate that 5-10% of virtually all forms of cancer are due to a primary hereditary etiology. However, a hereditary cancer diagnosis is often missed because the family history of cancer is given short shrift in medical practice. Hereditary nonpolyposis colorectal cancer (HNPCC) certainly fits this estimate, although some studies suggest that a minimum of 2% with a range as high as 10% of the total colorectal cancer burden is due to HNPCC. Mutations in one of the four mismatch repair genes, i.e., hMSH2, hMLH1, hPMS1, and hPMS2, account for about 70% of HNPCC kindreds. Other germ-line mutations are likely to be identified to account for the remainder of HNPCC patients. By far the most common HNPCC mutations involve hMSH2 and hMLH1, with hPMS1 and hPMS2 accounting for only about 3% of such families. Prior to these molecular genetic discoveries, the genetic counselor could only provide the patient with an estimate of a 50% likelihood of manifesting HNPCC based on the counselee having one or more first-degree relatives manifesting syndrome cancers in their direct genetic lineage. Because DNA testing has become available in families with known mutations, we have provided pretest group education in the form of a family information service with intensive education about the natural history, genetic risk, surveillance, and options for management of HNPCC, as well as discussion of the potential for fear, anxiety, apprehension, and insurance or employer discrimination that might impact on this DNA testing. Following informed consent, these relatives were then counseled on a one-to-one basis. Using DNA-based genetic counseling involving hMSH2 or hMLH1, we have provided this service to four extended HNPCC kindreds. Details of this genetic counseling experience on these four kindreds will be discussed.

The effect of changing the inertia of a trans-tibial dynamic elastic response prosthesis on the kinematics and ground reaction force patterns

The aim of this study was to assess, by means of gait analysis, the effect on the gait of a trans-tibial amputee of altering the mass and the moment of inertia of a dynamic elastic response prosthesis. One male amputee was analysed for four to five walking trials at normal and fast cadences, using the VICON system of motion analysis and an AMTI force plate. The kinematic variables of cadence, swing time, single support time and joint angles for the knee and hip on the affected and intact sides were analysed. The ground reaction force was also analysed. The sample size was limited to one as an example to indicate the changes which are possible through simply changing the inertial characteristics. Descriptive statistics are used to demonstrate these changes. Three mass conditions for the prosthesis were analysed m1: 1080g; m2: 1080 + 530g; m3: 1080 + 1460g. The m1 condition is the mass of the prosthesis with no added weight while m2 and m3 were attachments of the same geometrical shape but were made from different materials. It was felt that the large mass range would highlight biomechanical adjustments as a result of its alteration. The effect on selected temporal characteristics were that as the speed increased the cadence changed and the affected side single support times as a percentage of the gait cycle were altered. The effect on the joint angles was also apparent at the hip and knee of both sides. The ground reaction force patterns were similar for all three mass conditions, though the impact peak which was evident in the intact limb was missing, indicating a shock absorbing property in the prosthesis. Clearly, changing the mass and moment of inertia has an effect on the kinematic variables of gait and should be considered when designing a prosthesis.

A descriptive study of BRCA1 testing and reactions to disclosure of test results

BACKGROUND

The identification of the BRCA1 gene is a powerful tool for predicting a patient's lifetime risk for carcinoma of the breast and ovary when she has hereditary breast/ovarian carcinoma (HBOC) syndrome. The process of BRCA1 testing and genetic counseling and participants' reactions to test results, are described.

METHODS

Education about the natural history of HBOC syndrome and the pros and cons of genetic testing was provided to 14 HBOC families comprised of 2549 bloodline relatives. Of these, 388 underwent DNA testing. After informed consent was given by participants, formal linkage analysis and gene mutation studies were performed on the families. Qualitative data on intentions and emotional reactions were collected by physicians/counselors during the genetic counseling sessions.

RESULTS

Of those tested, 181 received their results after further genetic counseling. Seventy-eight of them were positive and 100 were negative for BRCA1 gene mutation. Three had ambiguous findings. The most common reasons given for seeking DNA testing were concern about risk to children and concern about surveillance and prevention. Prophylactic mastectomy was considered by 35% of women who tested positive, whereas prophylactic oophorectomy was considered an important option by 76%. Twenty-five percent of both BRCA1 positive and negative individuals were concerned about discrimination by insurance companies. Eighty percent of those who tested negative reported emotional relief, whereas over one-third of those who tested positive reported sadness, anger, or guilt.

CONCLUSIONS

DNA testing of patients with HBOC syndrome must be performed in the context of genetic counseling. The authors' results demonstrate the many complex clinical and nonclinical issues that are important in this process.

A comparison of two pertussis epidemics in Auckland

AIM

To determine if the addition of the 6 week dose of pertussis vaccine in 1984 was associated with any change in the hospitalisation rate for children with pertussis and the higher hospitalisation rates for Maori and Pacific Islander children with pertussis.

METHODS

DESIGN

Population based study of pertussis hospitalisations using a retrospective chart review of hospitalisation data for children during the 1991 epidemic, which was compared to previously published data from the 1982 epidemic.

SETTING

Princess Mary and Middlemore hospitals, Auckland.

SUBJECTS

Children aged 0-14 years resident in metropolitan Auckland and hospitalised in Auckland during 1982 or 1991 with pertussis.

MEASUREMENTS

Hospitalisation rates were calculated as number of children with a discharge diagnosis of pertussis per 1000 children aged 0-14 years based on 1981 and 1991 census data. 1982 data were converted to person-years as published report was for an 8 month period. Hospitalisation rates were compared as a relative risk (RR) of hospitalisation in 1991 versus 1982.

RESULTS

There were 84 cases during 8 months in 1982 and 66 cases in 1991. Rates of hospitalisation by ethnic group; in 1982 were 0.24 Other/European (OE), 1.98 Maori (M), 1.37 Pacific Islander (PI); and in 1991 were 0.22 OE, 0.51 M, 0.40 PI. Compared to 1982 the relative risk of hospitalisation in 1991 adjusted for ethnicity was 0.43 (CI 0.33, 0.58, p < 0.0001). Compared to 1982 there was a significant reduction in the hospitalisation rate in 1991 for M (RR = 0.26, CI 0.16, 0.43, p < 0.0001); and PI children (RR = 0.29, CI 0.16, 0.54, p < 0.0001); but not for OE children (RR = 0.91, 95% CI 0.57, 1.46, p = 0.70).

CONCLUSIONS

There was a significant reduction in the rate of hospitalisation for pertussis in 1991 compared to 1982. This reduction in hospitalisation rate was due to a reduction in rates for Maori and Pacific Islander children.

Information needs and decisional preferences in women with breast cancer

OBJECTIVE

To determine the degree of involvement women with breast cancer wanted in medical decision making, extent to which they believed they had achieved their preferred level of involvement, and types of information they judged to be most important.

DESIGN AND SETTING

Cross-sectional survey at 2 tertiary oncology referral clinics and 2 community hospital oncology clinics in Winnipeg, Manitoba.

PATIENTS

Consecutive sample of 1012 women with a confirmed diagnosis of breast cancer who were scheduled for a visit at 1 of 4 hospital oncology clinics.

MAIN OUTCOME MEASURES

The following measures were used: (1) Preferences about various levels of participation in treatment decision making; (2) the extent to which subjects believed they had achieved their preferred levels of involvement in decision making; and (3) priority needs for information and how these needs differed by selected sociodemographic, disease, and treatment variables.

RESULTS

A total of 22% of women wanted to select their own cancer treatment, 44% wanted to select their treatment collaboratively with their physicians, and 34% wanted to delegate this responsibility to their physicians. Only 42% of women believed they had achieved their preferred level of control in decision making. The 2 most highly ranked types of information were related to knowing about chances of cure and spread of disease. Women younger than 50 years rated information about physical and sexual attractiveness as more important than did older women (P<.001); women older than 70 years rated information about self-care as more important than did younger women (P=.002); and women who had a positive family history of breast cancer rated information about family risk as more important than did other women (P=.03).

CONCLUSIONS

The substantial discrepancy between women's preferred and attained levels of involvement in treatment decision making suggests that systematic approaches to assess and respond to women's desired level of participation in treatment decision making need to be evaluated. Priorities for information identified in this study provide an empirical basis to guide communication with women seeking care for breast cancer.