Hemoglobin Variant in Disguise

BACKGROUND

Hemoglobinopathies include thalassemia syndromes, where production of one or more globin subunits of hemoglobin (Hb) is reduced, and structural Hb variants. Over 1000 disorders of Hb synthesis and/or structure have been identified and characterized, with phenotypes ranging from having severe clinical manifestations to clinically silent. Various analytical methods are used to phenotypically detect Hb variants. However, molecular genetic analysis is a more definitive method for Hb variant identification.

CASE REPORT

Here, we report a case of a 23-month-old male with results from capillary electrophoresis, gel electrophoresis (acid and alkaline), and high-performance liquid chromatography most consistent with HbS trait. Specifically, capillary electrophoresis showed slightly elevated HbF and HbA2, HbA of 39.4% and HbS of 48.5%. The HbS percentage was consistently higher than expected (typically 30-40%) for HbS trait with no concurrent thalassemic indices. The patient has not experienced any clinical complications due to the hemoglobinopathy and he is thriving.

CONCLUSION

Molecular genetic analysis revealed the presence of compound heterozygosity for HbS and Hb Olupona. Hb Olupona is an extremely rare beta-chain variant that appears as HbA on all three common methods used for phenotypic Hb analysis. When the fractional concentration of Hb variants is unusual, more definitive methods should be used, such as mass spectrometry or molecular genetic testing. In this case, incorrectly reporting this result as HbS trait is unlikely to have a significant clinical impact, as current evidence suggests Hb Olupona is not a clinically significant variant.

Sickle cell bone disease and response to intravenous bisphosphonates in children

Children with sickle cell disease (SCD) have the potential for extensive and early-onset bone morbidity. This study reports on the diversity of bone morbidity seen in children with SCD followed at three tertiary centers. IV bisphosphonates were effective for bone pain analgesia and did not trigger sickle cell complications.

INTRODUCTION

To evaluate bone morbidity and the response to intravenous (IV) bisphosphonate therapy in children with SCD.

METHODS

We conducted a retrospective review of patient records from 2003 to 2019 at three Canadian pediatric tertiary care centers. Radiographs, magnetic resonance images, and computed tomography scans were reviewed for the presence of avascular necrosis (AVN), bone infarcts, and myositis. IV bisphosphonates were offered for bone pain management. Bone mineral density was assessed by dual-energy X-ray absorptiometry (DXA).

RESULTS

Forty-six children (20 girls, 43%) had bone morbidity at a mean age of 11.8 years (SD 3.9) including AVN of the femoral (17/46, 37%) and humeral (8/46, 17%) heads, H-shaped vertebral body deformities due to endplate infarcts (35/46, 76%), and non-vertebral body skeletal infarcts (15/46, 32%). Five children (5/26, 19%) had myositis overlying areas of AVN or bone infarcts visualized on magnetic resonance imaging. Twenty-three children (8/23 girls) received IV bisphosphonate therapy. They all reported significant or complete resolution of bone pain. There were no reports of sickle cell hemolytic crises, pain crises, or stroke attributed to IV bisphosphonate therapy.

CONCLUSION

Children with SCD have the potential for extensive and early-onset bone morbidity. In this series, IV bisphosphonates were effective for bone pain analgesia and did not trigger sickle cell complications.

AB1426 PREDICTORS OF RHEUMATIC TOXICITIES OF IMMUNE CHECKPOINT INHIBITORS AND CANCER OUTCOMES IN PATIENTS WITH ADVANCED MELANOMA

Background

Immune checkpoint inhibitors (ICIs) including monoclonal antibodies to PD-1 and CTLA-4 have activity across various cancers. Dedicated cohort studies have examined the epidemiology and clinical course of rheumatic toxicities (1–3) and the effect of pre-existing autoimmune disease has been explored (4), with limited assessment of the effect of non-immune mediated rheumatic disease (3). A positive association between ICI-induced rheumatic disease and favourable cancer outcomes has been suggested (1,2), although derived from heterogenous cancer populations.

Objectives

To identify risk factors for the development of ICI-induced rheumatic disease and predictors of cancer outcomes in patients with advanced melanoma.

Methods

A single-centre observational study of patients with stage III or IV melanoma receiving all available ICI therapies, who completed a for-purpose questionnaire to capture rheumatic symptoms and risk factors upon recruitment and at 12-months. Symptom severity was assessed according to patient reported measures such as visual analogue scale (VAS) scores for pain. Clinical details were extracted from patients’ medical records. Predictors of rheumatic toxicities and cancer outcomes were identified through regression analysis.

Results

Amongst 147 eligible patients, the prevalence of new or worsening rheumatic symptoms was 32.5% at recruitment and 21% at 12 months. The incidence of documented arthralgia, inflammatory arthritis and PMR-like syndrome was 39.5%, 5.4% and 3.4% respectively. Binary logistic regression identified pre-existing symptomatic rheumatic disease, including non-immune mediated rheumatic disease, as the primary risk factor for developing rheumatic toxicities (OR 3.161). Continuation of ICI therapy (OR 16.52), followed by rheumatic toxicities (OR = 4.368) were predictors of favourable tumour response.

Conclusion

Rheumatic toxicities of ICI therapy commonly affect patients with melanoma and are more likely to occur in patients with pre-existing autoimmune and non-immune mediated rheumatic disease. Continuation of ICI therapy improves cancer outcomes and can be facilitated by early detection of rheumatic symptoms using patient reported outcome measures.

Table 1.

Bivariate logistic regression of predictors of patient-reported rheumatic toxicity. Sig., Significance; OR, Odds ratio; CI, confidence interval; BRAF/MEK, BRAF and MEK inhibitors; PD-1, Programmed Cell Death protein – 1; CTLA-4, Cytotoxic T-lymphocyte-associated protein.

Figure 1.

A) Receiver-operator curve for accuracy of binary logistic regression model clinician-recorded rheumatic disease. (B) Area under receiver-operator curve. Test result variable(s): predicted probability. AUROC, Area Under Receiver-Operator Curve; Std. Error, Standard Error; Sig., Significance.

(a) Under the nonparametric assumption

(b) Null hypothesis: true area = 0.5

References

[1]Kostine M, Rouxel L, Barnetche T, Veillon R, Martin F, Dutriaux C, et al. Rheumatic disorders associated with immune checkpoint inhibitors in patients with cancer-clinical aspects and relationship with tumour response: a single-centre prospective cohort study. Ann Rheum Dis. 2018;77(3):393–8.

[2]Braaten TJ, Brahmer JR, Forde PM, Le D, Lipson EJ, Naidoo J, et al. Immune checkpoint inhibitor-induced inflammatory arthritis persists after immunotherapy cessation. Ann Rheum Dis. 2019;332–8.

[3]Buder-Bakhaya K, Benesova K, Schulz C, Anwar H, Dimitrakopoulou-Strauss A, Weber TF, et al. Characterization of arthralgia induced by PD-1 antibody treatment in patients with metastasized cutaneous malignancies. Cancer Immunol Immunother. 2018;67(2):175–82.

[4]Menzies AM, Johnson DB, Ramanujam S, Atkinson VG, Wong ANM, Park JJ, et al. Anti-PD-1 therapy in patients with advanced melanoma and preexisting autoimmune disorders or major toxicity with ipilimumab. Ann Oncol. 2017;28(2):368–76.

Disclosure of Interests

Alana Bruce: None declared, Alexander Menzies Consultant of: A.M.M. has participated in advisory boards for BMS, MSD, Novartis, Roche, Pierre-Fabre, Georgina Long Consultant of: GVL is consultant advisor for Aduro Biotech Inc, Agenus Inc, Amgen Inc, Array Biopharma inc, Boehringer Ingelheim International GmbH, Bristol-Myers Squibb, Evaxion Biotech A/S, Hexel AG, Highlight Therapeutics S.L., Merck Sharpe & Dohme, Novartis Pharma AG, OncoSec, Pierre Fabre, QBiotics Group Limited, Regeneron Pharmaceuticals Inc, Specialised Therapeutics Australia Pty Ltd., Brian Fernandes: None declared, Fredrick Joshua Consultant of: F.J. has performed clinical trials and participated in advisory boards for Abbvie, Pfizer, Novartis, Sanofi, Eli Lily and Roche

56 A Quality Improvement Project to Assess and Refine the Handover Process at Morning Trauma Meetings

Aim

Poor handover and inadequate transmission of clinical information between shifts can result in patient harm. This study was designed to evaluate the impact of implementing a handover protocol on the quality of information exchanged in the trauma handover meetings in a UK district general hospital.

Method

A prospective single centre observational study was performed at an acute NHS trust, using the define, measure, analyse, improve and control (DMAIC) methodology. Ten consecutive weekday trauma meetings, involving 43 patients, were observed to identify poor practices in handover. This data was used in conjunction with the Royal College of Surgeon’s recommendations for effective handover (2007) to create a standard operating protocol (SOP). Following the implementation of the SOP, a further eight consecutive weekday trauma meetings, involving a further 47 patients, were observed. The data collection was performed by five trained independent observers. The data was analysed using t-test for quantitative variables and chi-square or Fisher’s exact tests for categorical variables.

Results

An improvement in the trauma handover was demonstrated in multiple aspects of handover including patient’s past medical history, injury date, results, diagnosis, consent, mark and starvation status (all p < 0.001). Subgroup analyses showed that handover of neck of femur patients including information on mobility (p = 0.04), Nottingham Hip Fracture Score (p = 0.01), next of kin discussion (p = 0.075) and resuscitation status (p = 0.001) all improved following our interventions.

Conclusions

These results demonstrate that the implementation of a well-structured handover protocol can improve the transmission of critical information in trauma meetings.

Diagnosing ventilator-associated pneumonia (VAP) in UK NHS ICUs: the perceived value and role of a novel optical technology

BACKGROUND

Diagnosing ventilator-associated pneumonia (VAP) in an intensive care unit (ICU) is a complex process. Our aim was to collect, evaluate and represent the information relating to current clinical practice for the diagnosis of VAP in UK NHS ICUs, and to explore the potential value and role of a novel diagnostic for VAP, which uses optical molecular alveoscopy to visualise the alveolar space.

METHODS

Qualitative study performing semi-structured interviews with clinical experts. Interviews were recorded, transcribed, and thematically analysed. A flow diagram of the VAP patient pathway was elicited and validated with the expert interviewees. Fourteen clinicians were interviewed from a range of UK NHS hospitals: 12 ICU consultants, 1 professor of respiratory medicine and 1 professor of critical care.

RESULTS

Five themes were identified, relating to [1] current practice for the diagnosis of VAP, [2] current clinical need in VAP diagnostics, [3] the potential value and role of the technology, [4] the barriers to adoption and [5] the evidence requirements for the technology, to help facilitate a successful adoption. These themes indicated that diagnosis of VAP is extremely difficult, as is the decision to stop antibiotic treatment. The analysis revealed that there is a clinical need for a diagnostic that provides an accurate and timely diagnosis of the causative pathogen, without the long delays associated with return of culture results, and which is not dangerous to the patient. It was determined that the technology would satisfy important aspects of this clinical need for diagnosing VAP (and pneumonia, more generally), but would require further evidence on safety and efficacy in the patient population to facilitate adoption.

CONCLUSIONS

Care pathway analysis performed in this study was deemed accurate and representative of current practice for diagnosing VAP in a UK ICU as determined by relevant clinical experts, and explored the value and role of a novel diagnostic, which uses optical technology, and could streamline the diagnostic pathway for VAP and other pneumonias.

543 Improving the Management of Acute Ureteric Colic in A Multi-Centre District General Hospital: A Closed-Loop Audit

Introduction

The British Association of Urological Surgeons (BAUS) released guidance in 2018 regarding the optimum management of acute ureteric colic: a condition which can present as a surgical emergency. Our aim was to review the current practice at our hospital in diagnosing and managing acute ureteric colic and ultimately, implement sustainable change to address any areas of limitations.

Method

The following data was retrospectively collected for of all patients admitted with acute ureteric colic: investigations performed, medications administered, details of surgical intervention and follow-up. 1st Cycle: March 2017 to February 2018. Intervention: Teaching sessions delivered to staff (including doctors and nurses) in the A&E and urology department. 2nd Cycle: January 2019 to December 2019.

Results

268 patients presented to A&E with ureteric colic – 18% increase from previous year. On admission: 60.4% of patients had serum calcium checked, 97.7% had a CT KUB performed within 24 hours and 67.2% were given NSAIDs; this is a 20.4%, 0.4% and 5.2% increase from the previous year, respectively. Only 31.3% of patients had an acute surgical intervention. The average wait time for clinic follow-up was reduced to 41 days following departmental education, but only 26.4% of patients were seen within the BAUS advised 4-week timeframe.

Conclusions

Re-audit showed distinct improvement in the management of acute ureteric colic. Thus, departmental education strategies have had a positive impact. It is recommended that the reservation of one daily elective theatre slot for an emergency operation and a computerised clinic booking system will further optimise our management in line with BAUS guidance.

Oropharyngeal histoplasmosis: a report of 10 cases

A wide differential diagnosis must be entertained in patients with unusual oral and pharyngeal ulcerations. A mucosal biopsy is essential. We retrospectively reviewed 10 cases from the Infectious Diseases Division at Mayo Clinic Rochester (MN, USA), in which the diagnosis proved to be Histoplasma capsulatum infection. Between 1995 and 2016, 10 patients were diagnosed with oropharyngeal histoplasmosis. Common presenting symptoms included weight loss, weakness and oropharyngeal pain with ulcerations. Despite specialty evaluation at other facilities, diagnostic delay occurred in six patients due to lack of biopsy or fungal staining. Yeast forms consistent with H. capsulatum were identified in the biopsy specimens of all our patients. Treatment included intravenous amphotericin B and prolonged courses of azoles. Oral histoplasmosis occurred in both immunocompetent and immunosuppressed patients, and was a manifestation of disseminated infection. Severe pain involving all areas of the mouth was typical. Diagnostic delay may be avoided by early biopsy using fungal stains.

Shape Evolution in Neutron-Rich Krypton Isotopes Beyond N=60: First Spectroscopy of ^{98,100}Kr

We report on the first γ-ray spectroscopy of low-lying states in neutron-rich ^{98,100}Kr isotopes obtained from ^{99,101}Rb(p,2p) reactions at ∼220  MeV/nucleon. A reduction of the 2_{1}^{+} state energies beyond N=60 demonstrates a significant increase of deformation, shifted in neutron number compared to the sharper transition observed in strontium and zirconium isotopes. State-of-the-art beyond-mean-field calculations using the Gogny D1S interaction predict level energies in good agreement with experimental results. The identification of a low-lying (0_{2}^{+}, 2_{2}^{+}) state in ^{98}Kr provides the first experimental evidence of a competing configuration at low energy in neutron-rich krypton isotopes consistent with the oblate-prolate shape coexistence picture suggested by theory.

Contrasting stories of life-threatening illness: a narrative inquiry

BACKGROUND

Advances in science and technology have resulted in longer lives for people with life-threatening illnesses. However, little research compares the stories of people with different life-threatening illnesses.

OBJECTIVES

The objectives of this study were to explore and contrast how people story and re-story life-threatening illness specifically cancer, chronic kidney disease (CKD) and HIV.

DESIGN

Narrative inquiry within a social constructionist perspective was used.

METHODS

A total of 113 in-depth interviews were conducted with 32 participants over a period of three years.

PARTICIPANTS

Study participants included 32 people: 10 with cancer, 14 with CKD and 8 with HIV/AIDS. Participants varied in age (37-83 years old, mean=61.2 years), gender (17 men and 14 women), location (urban and rural), time post-diagnosis (median=8 years), intensity or invasiveness of treatment, and prognosis (continuous treatment, remission, cure, palliative).

RESULTS

Participants described living with a life-threatening illness as a delicate balance. They focused on living their lives yet were fully and acutely aware of their own mortality. There was an undercurrent of sustained uncertainty that permeated their lives. Stories of life-threatening illness differed across the three illness groups and shifted over time as disease trajectories changed. Each disease brought specific challenges. With cancer, turning points and uncertainty were prominent. With CKD, a stealthy beginning to life-extending treatment through dialysis or transplant was evident, and with HIV, a shift from a perceived death sentence to a focus on hope and living was notable.

CONCLUSIONS

Findings revealed that trajectories of illness for participants living with cancer, CKD and HIV are complex and differ markedly across the groups. Narratives shifted across all of the illness groups as participants navigated and re-storied the terrains of their life-threatening illness. Findings illuminated the need for health care providers to focus on person specific and contextualized aspects of the illness experience.

FOXO3 expression during colorectal cancer progression: biomarker potential reflects a tumour suppressor role

BACKGROUND

In previous studies, the Forkhead/winged-helix-box-class-O3 (FOXO3) transcription factor has displayed both tumour suppressive and metastasis-promoting properties.To clarify its role in human colorectal cancer (CRC) progression, we examined in vivo FOXO3 expression at key points of the metastatic cascade.

METHODS

Formalin-fixed paraffin-embedded resection specimens from normal colon, adenomas, primary CRC specimens of different pathological stage and CRC specimens with matched liver metastases were used to generate three separate custom-designed tissue microarray (TMA) representations of metastatic progression. Triplicate cores, immunostained for FOXO3 were scored semiquantitatively by two investigators.

RESULTS

The FOXO3 expression is significantly reduced in CRC specimens compared with normal tissue, and progressive FOXO3 downregulation is associated with advancing pathological stage. In addition, recurrent stage I/II primary tumours show a significantly lower FOXO3 expression compared with stage-matched non-recurrent tumours. When stratified according to high and low FOXO3 expression, mean disease-free survival in the low-expressing group was 28 months (95% CI 15.8-50.6) compared with 64 months (95% CI 52.9-75.4) in the high-expressing group.

CONCLUSION

We have demonstrated an association between low FOXO3 expression and CRC progression in vivo using purpose-designed TMAs. Forkhead/winged-helix-box-class-O3 may represent a novel biomarker of nodal and distant disease spread with clinical utility in CRC.

Temperature dependence of the disulfide perturbation to the triplet state of tryptophan

Variability in the temperature dependence of disulfide quenching of the tryptophan phosphorescence of globular proteins in rigid glasses is illustrated with lysozyme and alpha-bungarotoxin. A laser-pulsed phosphorescence study of this short-range interaction with a model indole-disulfide system is described. The perturbation of secondary dibutyl disulfide on the triplet state of the indole moiety in 2-(3-indolyl)ethyl phenyl ketone in rigid media is found to display a bimodal temperature dependence. The quenching rate constant at contact between chromophore and perturber is observed to be temperature independent below 30 K, but to increase with temperature between 30 and 100 K with an activation energy of approximately 200 cm(-1). The results suggest that the underlying quenching interaction involves a photo-induced one-electron transfer from the excited state of indole to the disulfide.

Dolly for dinner? Assessing commercial and regulatory trends in cloned livestock

As cloning technologies become more widely established, will products enter the food chain sooner than regulatory agencies and the public might be prepared for?

Identification of an ataxia telangiectasia-mutated protein mediated surveillance system to regulate Bcl-2 overexpression

Bcl-2 can both promote and attenuate tumorigenesis. Although the former function is relatively well characterized, the mechanism of the latter remains elusive. We report here that enforced Bcl-2 expression in MCF7 cells stabilizes p53, induces phosphorylation of p53 serine 15 (p53pSer15) and inhibits MCF7 cell growth. Consistent with p53 Ser15 being a target of ataxia telangiectasia mutated protein(ATM)/ATR (ATM- and rad3-related) in the DNA damage response, Bcl-2 activates ATM by inducing ATM Ser1981 phosphorylation, which is accompanied with the phosphorylaton of two additional ATM substrates, Chk2 Thr68 and H2AX Ser139. Downregulation of ATM using a specific small interference RNA fragment (ATMRNAi) abolished Bcl-2-induced p53pSer15 and Bcl-2-mediated growth inhibition of MCF7 cells. Ectopic expression of a dominant-negative p53 mutant, p53175H, partially rescued this growth inhibition. Taken together, these observations demonstrate the contribution of ATM-p53 function to Bcl-2-mediated inhibition of MCF7 cell growth, indicating an ATM-mediated surveillance system for regulating Bcl-2 overexpression. Consistent with this concept, we found that MCF7 cells express Bcl-2 heterogeneously with 34.5% of cells being Bcl-2 negative. In general, Bcl-2-positive MCF7 cells proliferate slower than those of Bcl-2 negative. Thus, we provide evidence suggesting that activation of ATM suppresses Bcl-2-induced tumorigenesis, and that attenuation of ATM function may be an important event in breast cancer progression.

ERK activity facilitates activation of the S-phase DNA damage checkpoint by modulating ATR function

Although Erk kinase has been recently reported to function in the DNA damage response, the mechanism governing this process is unknown. We report here that hydroxyurea (HU) activates Erk via MEK1, a process that is sensitized by a constitutively active MEK1 (MEK1Q56P) and attenuated by a dominant-negative MEK1 (MEK1K97M). While ectopic MEK1Q56P sensitized HU-induced S-phase arrest, inhibition of Erk activation via U0126, PD98059, and MEK1K97M attenuated the arrest, and thereby enhanced cells to HU-induced toxicity. Taken together, we demonstrate an important contribution of Erk to the activation of the S-phase DNA damage checkpoint. This can be attributed to Erk's regulatory role in modulating ATR function. Inhibition of Erk activation with U0126/PD98059 and MEK1K97M substantially reduced HU-induced ATR nuclear foci, leading to a dramatic reduction of gammaH2AX and its nuclear foci. Reduction of MEK1 function by a small interference RNA (siRNA) MEK1 and ectopic MEK1K97M significantly decreased HU-induced gammaH2AX. Conversely, ectopic MEK1Q56P enhanced gammaH2AX foci. Furthermore, immunofluorescent and cell fractioning experiments revealed cytosolic and nuclear localization of ATR. HU treatment caused the redistribution of ATR from the cytosol to the nucleus, a process that is inhibited by U0126. Collectively, we show that Erk kinase modulates HU-initiated DNA damage response by regulating ATR function.

A Comparison of GluR-A-Deficient and Wild-Type Mice on a Test Battery Assessing Sensorimotor, Affective, and Cognitive Behaviors

Previous studies have demonstrated a spatial working memory deficit in glutamate receptor (GluR)-A (GluR1) AMPA receptor subunit knockout mice. The present study evaluated male and female wild-type and GluR-A-/- mice on a test battery that assessed sensorimotor, affective, and cognitive behaviors. Results revealed a behavioral phenotype more extensive than previously described. GluR-A-/- mice were hyperactive, displayed a subtle lack of motor coordination, and were generally more anxious than wild-type controls. In addition, they showed a deficit in spontaneous alternation, consistent with previous reports of a role for GluR-A-dependent plasticity in hippocampus-dependent, spatial working memory. Although changes in motor coordination or anxiety cannot explain the dissociations already reported within the spatial memory domain, it is clear that they could significantly affect interpretation of results obtained in other kinds of behavioral tasks.

Analysis of cervico-vaginal (Papanicolaou) smears, in girls 18 years and under

This study was conducted retrospectively at the Queen Elizabeth Hospital and a private laboratory in Barbados to determine the types of epithelial abnormalities in cervico-vaginal Papanicolaou (Pap)-stained smears, and their clinical implications in Barbadian girls, 18 years and under, during the five-year period January 1995 to December 1999. Two hundred and sixty-five Pap smears from 236 patients were examined and the gynaecological history, initial and repeat Pap smear diagnoses, and histology reports of these patients were analyzed. Of the 236 first-visit smears, 94 (39.8%) were abnormal with 36 (15.3%) displaying cytologic features of squamous intra-epithelial lesions (SIL), (33 low grade and 3 high grade). A diagnosis of atypical squamous cells of undetermined significance (ASCUS) was reported in the remaining 58 (24.5%) abnormal smears, of which 35 (60.3%) were suspected to be related to human papillomavirus (HPV) infection. Twenty-two (23.4%) of these 94 patients, who had abnormal smears of either ASCUS or low grade squamous intra-epithelial lesions (LSIL) were re-evaluated within six to twelve months of the initial abnormal Pap smear diagnosis. Eight of these 22 patients (36.4%) had histological diagnosis of LSIL inclusive of cervical intra-epithelial neoplasia grade 1 (CIN 1) and condylomata. High-risk HPV DNA types were detected in two of these eight patients (25%). The study confirms that sexually active teenage girls are at risk of developing SIL and high-risk HPV infection. Screening of sexually active teenaged girls by Pap smears followed by other appropriate investigative procedures is recommended.

Hepatic progenitors and strategies for liver cell therapies

Liver cell therapies, including liver cell transplantation and bioartificial livers, are being developed as alternatives to whole liver transplantation for some patients with severe liver dysfunction. Hepatic progenitors are proposed as ideal cells for use in these liver cell therapies given their ability to expand extensively, differentiate into all mature liver cells, have minimal immunogenicity, be cryopreservable, and reconstitute liver tissue when transplanted. We summarize our ongoing efforts to develop clinical programs of hepatic progenitor cell therapies with a focus on hepatic stem cell biology and strategies that have emerged in analyzing that biology.

Depression in primary care. 1: elderly patients' disclosure of depressive symptoms to their doctors

BACKGROUND

This article examines some of the factors responsible for older patients' decision to report current depressive symptoms to their general medical practitioner. A companion article considers factors contributing to general practitioners' (GPs') recognition of major depressive episode when it was present.

METHODS

A survey was conducted of a stratified sample of 1,021 patients aged 70+ years of 30 GPs in Melbourne, Australia, to gauge the prevalence of depressive symptoms, the frequency with which patients had informed GPs of their symptoms, and GPs' recognition of major depressive episodes. Patients and informants were questioned using the Canberra Interview for the Elderly, which generates rigorous ICD-10 research diagnoses.

RESULTS

Logistic regression analysis showed that symptom disclosure was associated in descending order of importance with higher depressive scores, previous contact with a psychiatrist, and female gender. Even so, 48% of persons with ICD-10 moderate or severe depressive episode had not reported any current complaints to their doctor at the time of interview.

CONCLUSION

Older patients often do not report depressive symptoms to their medical practitioner. Men and patients lacking "psychological mindedness" may be at special risk.

Depression in primary care. 2: general practitioners' recognition of major depression in elderly patients

BACKGROUND

It is important that serious depressive illness be recognized and treated appropriately by primary care practitioners. This and the preceding article in this issue examine (a) factors responsible for older patients' decision to report depressive symptoms to their doctor and (b) general practitioners' (GPs') recognition of depression when it was present.

METHODS

A survey was conducted of a stratified sample of 1,021 patients aged 70+ years of 30 GPs in Melbourne, Australia, using the Canberra Interview for the Elderly, which generates rigorous ICD-10 research diagnoses.

RESULTS

GPs' ratings of depression were best predicted in descending order of importance by patients' past contact with a psychiatrist, the doctor's view that a patient did not have dementia, the number of current depressive symptoms, patients' disclosure of these symptoms, and current physical pain. Physicians' assessments of patients' mood concurred with research diagnoses in 23 of 35 (66%) cases of ICD-10 mild depressive episode and 23 of 26 (88%) cases of moderate or severe depressive episode. GPs were unaware, however, of many depressive symptoms and often rated patients as being depressed when they were not.

CONCLUSION

The use of a simple checklist of depressive symptoms would lead to a dramatic improvement in doctors' knowledge of patients' current psychiatric status.

From competition to collaboration in the delivery of health care: England and Scotland compared

AIM

The purpose of this paper is to outline and critically appraise the NHS reforms that were operationalized in April 1999.

DISCUSSION

The paper recognizes that there are important differences between England and Scotland in the design and implementation of change. Differences are discernible in terms of the organization of the commissioning role and of the acute hospital sector, but more significant differences are evident in terms of the nature and organization of primary care.

CONCLUSIONS

The paper concludes by indicating that a major challenge exists in the change management agenda with reference to primary care. Thus, while differences exist both north and south of the border, a shared feature is that the change management agenda in both England and Scotland is formidable. The main element of this challenge is that GPs have, in different ways, had to be drawn into the mainstream of the NHS.