How often do head and neck cancer patients raise concerns related to intimacy and sexuality in routine follow-up clinics?

Intimacy and sexuality problems are underreported in head and neck cancer patients. The aim of this study was to collate the various prompts available in a routine follow-up clinic through the use of an intimacy screening question and Patient's Concerns Inventory (PCI), and to identify how often these problems were raised by patients and what possible actions took place as a consequence. 177 patients completed the intimacy screening question, PCI and UW-QOLv.4 at follow-up clinics, from October 2008 to January 2011. Case note review identified if intimacy was mentioned in clinic letters and if referral for support was made. On the intimacy screening question, 15 % (26) reported problems of considerable/some concern (24) or selected intimacy/sexuality on the PCI (2). The PCI identified that 9 of the 24 reporting the worst problems wanted the topic discussed in clinic, and clinic letters suggested that 5 of these discussed the issue in clinic with 4 being referred on, 3 to a clinical psychologist and 1 to a clinical nurse specialist. Intimacy problems are underreported in clinic reviews. It is a difficult subject to discuss. It will remain a potential unmet need unless attempts are made to advance the opportunities for patient screening, information leaflets, staff training on how to talk about such sensitive issues and referral for counselling.

Evaluating a systematic voiding programme for patients with urinary incontinence after stroke in secondary care using soft systems analysis and Normalisation Process Theory: findings from the ICONS case study phase

BACKGROUND

Urinary incontinence (UI) affects between 40 and 60% of people in hospital after stroke, but is often poorly managed in stroke units.

OBJECTIVES

To inform an exploratory trial by three methods: identifying the organisational context for embedding the SVP; exploring health professionals' views around embedding the SVP and measuring presence/absence of UI and frequency of UI episodes at baseline and six weeks post-stroke.

DESIGN

A mixed methods single case study included analysis of organisational context using interviews with clinical leaders analysed with soft systems methodology, a process evaluation using interviews with staff delivering the intervention and analysed with Normalisation Process Theory, and outcome evaluation using data from patients receiving the SVP and analysed using descriptive statistics.

SETTING

An 18 bed acute stroke unit in a large Foundation Trust (a 'not for profit' privately controlled entity not accountable to the UK Department of Health) serving a population of 370,000.

PARTICIPANTS

Health professionals and clinical leaders with a role in either delivering the SVP or linking with it in any capacity were recruited following informed consent. Patients were recruited meeting the following inclusion criteria: aged 18 or over with a diagnosis of stroke; urinary incontinence (UI) as defined by the International Continence Society; conscious; medically stable as judged by the clinical team and with incontinence classified as stress, urge, mixed or 'functional'. All patients admitted to the unit during the intervention period were screened for eligibility; informed consent to collect baseline and outcome data was sought from all eligible patients.

RESULTS

Organisational context: 18 health professionals took part in four group interviews. Findings suggest an environment not conducive to therapeutic continence management and a focus on containment of UI. Embedding the SVP into practice: 21 nursing staff took part in six group interviews. Initial confusion gave way to embedding of processes facilitated by new routines and procedures. Patient outcome: 43 patients were recruited; 28 of these commenced the SVP. Of these, 6/28 (21%) were continent at six weeks post-stroke or discharge.

CONCLUSION

It was possible to embed the SVP into practice despite an organisational context not conducive to therapeutic continence care. Recommendations are made for introducing the SVP in a trial context.

Nucleolar protein trafficking in response to HIV-1 Tat: rewiring the nucleolus

The trans-activator Tat protein is a viral regulatory protein essential for HIV-1 replication. Tat trafficks to the nucleoplasm and the nucleolus. The nucleolus, a highly dynamic and structured membrane-less sub-nuclear compartment, is the site of rRNA and ribosome biogenesis and is involved in numerous cellular functions including transcriptional regulation, cell cycle control and viral infection. Importantly, transient nucleolar trafficking of both Tat and HIV-1 viral transcripts are critical in HIV-1 replication, however, the role(s) of the nucleolus in HIV-1 replication remains unclear. To better understand how the interaction of Tat with the nucleolar machinery contributes to HIV-1 pathogenesis, we investigated the quantitative changes in the composition of the nucleolar proteome of Jurkat T-cells stably expressing HIV-1 Tat fused to a TAP tag. Using an organellar proteomic approach based on mass spectrometry, coupled with Stable Isotope Labelling in Cell culture (SILAC), we quantified 520 proteins, including 49 proteins showing significant changes in abundance in Jurkat T-cell nucleolus upon Tat expression. Numerous proteins exhibiting a fold change were well characterised Tat interactors and/or known to be critical for HIV-1 replication. This suggests that the spatial control and subcellular compartimentaliation of these cellular cofactors by Tat provide an additional layer of control for regulating cellular machinery involved in HIV-1 pathogenesis. Pathway analysis and network reconstruction revealed that Tat expression specifically resulted in the nucleolar enrichment of proteins collectively participating in ribosomal biogenesis, protein homeostasis, metabolic pathways including glycolytic, pentose phosphate, nucleotides and amino acids biosynthetic pathways, stress response, T-cell signaling pathways and genome integrity. We present here the first differential profiling of the nucleolar proteome of T-cells expressing HIV-1 Tat. We discuss how these proteins collectively participate in interconnected networks converging to adapt the nucleolus dynamic activities, which favor host biosynthetic activities and may contribute to create a cellular environment supporting robust HIV-1 production.

Limited effect on NS3-NS4A protein cleavage after alanine substitutions within the immunodominant HLA-A2-restricted epitope of the hepatitis C virus genotype 3a non-structural 3/4A protease

It has been well established that immunological escape mutations within the hepatitis C virus genotype (gt) 1a non-structural (NS) 3/4A protease are partly prevented by a reduction in viral protease fitness. Surprisingly little is known about whether similar mutations affect proteases from other genotypes. In the present study, we assessed both the HLA-A2-restricted CTL response and gt3a NS3/4A protease fitness. Similar to gt1, the 1073-1081 epitope was immunodominant within the gt3a-specific HLA-A2-restricted CTL response, despite sequence similarity of only 56 % between the gt1a and gt3a genes. However, unlike the gt1a NS3/4A protease, all residues within the gt3a 1073-1081 epitope could be replaced sequentially by alanine while retaining protease activity, at least in part.

Quality of life in older people with oral cancer

There is a growing elderly population presenting with, and surviving, oral cancer. Making decisions about treatment is complex, and is influenced in part by prognosis and expected outcomes for health-related quality of life (HRQoL). We used the University of Washington Head and Neck Quality of Life scale (UWQoL) to compare HRQoL in patients by age group at a time closest to one year after primary surgery. Survival was analysed using data from the Office for National Statistics. A consecutive series of 1091 patients treated curatively for oral squamous cell carcinoma (SCC) at the regional maxillofacial unit at Aintree University Hospital between 1992 and 2009 were included in the main analysis. UWQoL data for 638 patients were available from about one year after treatment. Older patients (65 years or over) reported better physical and emotional function notably in regard to appearance, speech, saliva (75 years and over), pain, shoulder, mood, and anxiety than younger patients with head and neck cancer treated by operation. In conclusion, older patients seem to cope and adjust well to treatment and this is reflected in their HRQoL scores, which are higher in many domains than those of younger patients with head and neck cancer.

Metabolomic profile of hepatitis C virus-infected hepatocytes

Hepatitis C virus (HCV) is capable of disrupting different facets of lipid metabolism and lipids have been shown to play a crucial role in the viral life cycle. The aim of this study was to examine the effect HCV infection has on the hepatocyte metabolome. Huh-7.5 cells were infected using virus produced by the HCV J6/JFH1 cell culture system and cells were harvested 24, 48, and 72-hours following infection. Metabolic profiling was performed using a non-targeted multiple platform methodology combining ultrahigh performance liquid chromatography/tandem mass spectrometry (UHPLC/MS/MS²) and gas chromatography/mass spectrometry (GC/MS). There was a significant increase in a number of metabolites involved in nucleotide synthesis and RNA replication during early HCV infection. NAD levels were also significantly increased along with several amino acids. A number of lipid metabolic pathways were disrupted by HCV infection, resulting in an increase in cholesterol and sphingolipid levels, altered phospholipid metabolism and a possible disruption in mitochondrial fatty acid transport. Fluctuations in 5′-methylthioadenosine levels were also noted, along with alterations in the glutathione synthesis pathway. These results highlight a number of previously unreported metabolic interactions and give a more in depth insight into the effect HCV has on host cell biochemical processes.

Designing integrated care pathways to facilitate acute hospital discharge: the role of routinely available statistics

Purpose

Typically around 30% of acute beds used by older people deliver care that could be provided in ‘non-acute’ settings. Such ‘avoidable’ bed use results in ‘delayed’ hospital discharges. This study examined this problem using statistics that are routinely collected but not routinely used to support service development.

Methods

Daily, hospital staff document the number of patients who are ‘clinically fit for discharge’ (but still in hospital) and the reasons for their extended stay. These data were analysed over a 2-month period at two acute hospitals in England.

Results

At hospital one there were 164 delayed patients with discharge delays ranging from 1 to 72 days (at hospital 2, 113 patients, delayed by 1–18 days). At hospital 1, 59.8% of patients were delayed by ≤7 days, 87.5% at hospital 2.

Total delayed bed days were 1674 at hospital 1: patients delayed by ≥8 days (40.2%) accounted for 80.0% of this figure. Figures for hospital 2 were 378 delayed days: 12.5% of patients delayed by ≥8 days generated 48.0% of this total. Resolving long delays involved complex negotiations between health and social care professionals, patients and carers.

Conclusions

Routinely available statistics can support pathway design but they underestimate the true scale of discharge delays. These results suggest that the development of integrated care pathways that focus on clinical care for specific conditions will have most impact on the number of patients experiencing discharge delays. To reduce the number of delayed bed days, pathways also need to embrace a multi-morbidity, whole system focus.

Elevated Serum Levels of Interferon‐γ–Inducible Protein–10 in Patients Coinfected with Hepatitis C Virus and HIV

Coinfection with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) is associated with an accelerated course of HCV infection and a faster progression to severe liver disease. We have investigated whether the development of liver disease in coinfected patients is associated with specific chemokine and cytokine production. Four cohorts--HCV/HIV-coinfected patients, HCV-monoinfected patients, HIV-monoinfected patients, and healthy control subjects--were studied. Serum levels of the 10-kDa interferon- gamma -inducible protein (IP-10) were higher in all 3 groups of infected patients than in control subjects (P<.0001). HCV/HIV-coinfected patients had significantly higher IP-10 levels than monoinfected patients. In HCV-monoinfected patients, liver fibrosis scores and liver enzyme levels were positively correlated with IP-10 levels. Elevated IP-10 levels are associated with and may contribute to liver damage in both HCV-monoinfected and HCV/HIV-coinfected patients.

Bovine umbilical hernia maps to the centromeric end ofBos taurusautosome 8

Twelve bull calves were produced by mating elite Israeli cows to "Glenhapton Enhancer", a Canadian Holstein bull. The frequency of umbilical hernia (UH) in the progeny of the sons ranged from 1 to 21%, consistent with the hypothesis that Enhancer is the carrier of major dominant or codominant gene with partial penetrance for UH. Five sons of Enhancer produced progeny with >10% frequency of UH including sire 3259, whereas progeny of three sons had <3% UH. A total of 116 grand-progeny of Enhancer, all progeny of 3259, were genotyped for 59 microsatellites spanning the 29 bovine autosomes. Of these offspring, 41 were affected. Significant differences in paternal allele frequencies between the affected and unaffected progeny groups were found for marker BMS1591 on bovine chromosome 8 (BTA8). The UH-associated paternal allele originated from Enhancer. The chromosomal segment associated with UH was more precisely mapped between UWCA47, on the centromeric end of BTA8 and RM321, 12 cM from the centromere. A maximum LOD score of 3.84 was obtained 2.5 cM from the centromere with a support interval of 8 cM. Haplotype analysis of eight sons of Enhancer suggested that the UH gene is located in the centromeric end of BTA8 beyond ARO71/ARO72. Thus, by integrating the results from progeny of sire 3259 and sons of Enhancer the location of the UH gene was further refined to the BTA8 segment between ARO71/ARO72 and UWCA47.

F-MuLV acceleration of myelomonocytic tumorigenesis in SV40 large T antigen transgenic mice is accompanied by retroviral insertion at Fli1 and a novel locus, Fim4

We describe here the development of a murine system for the identification of genes involved in myelomonocytic neoplasms. Transgenic C57BL/6J mice expressing SV40 early region under a myelomonocytic promoter develop histiocytic sarcomas with a latency of 167 days. We used retroviral proviral tagging to accelerate tumorigenesis and to uncover genetic changes that contribute to tumor development. Infection of transgenic mice with Friend murine leukemia virus (F-MuLV) shortened the latency of morbidity to 103 days (P< 0.001); this was associated with clonal proviral integrations in tumor DNA. As expected for F-MuLV, proviral insertions occurred at Fli1 in both transgenic and nontransgenic tumors. Four insertions were found at a novel locus, termed Fim4, on chromosome 6. This region is syntenic to human 7q32, a region that is commonly deleted in human myelodysplastic syndrome and acute myeloid leukemia. A murine BAC containing Fim4 was sequenced and analyzed, and while there was significant human-mouse homology in the area of the insertions, no candidate gene has been identified. Thus we have established a system to identify genes involved in myelomonocytic tumors, and have used it to identify Fim4, a new common site of proviral insertion. Study of this locus may provide insight into genes involved in AML-associated 7q32 deletions in humans.

Utilization of incontinence clinical practice guidelines

Clinical practice guidelines (CPGs) are evidence-based recommendations for best practice and have been developed with the assumption they will be embraced by practitioners; a further assumption is that clinical practice guidelines will improve the delivery of care. In this article, we provide a working definition of evidence-based practice, discuss the strengths and limitations of CPGs, describe the implementation of CPGs in the context of urinary incontinence, and consider the steps that the WOCN has taken to initiate evidence-based practice. Current issues are presented along with initiatives that have resulted in clinical practice guidelines on incontinence from the United States, United Kingdom, and Canada. On the basis of the current literature, it is concluded that clinical practice guidelines can play an important role in WOCN practice and that the implementation of guidelines may improve clinical practice. However, guidelines are only as valid as the evidence on which they are based and may not take into account gender or cultural differences or the effect that comorbid conditions can have on treatment outcomes. Finally, guidelines must follow a comprehensive approach that involves management and staff and includes education, facilitation, evaluation, feedback, and an understanding of change strategies.

A novel member of the WD-repeat gene family, WDR11, maps to the 10q26 region and is disrupted by a chromosome translocation in human glioblastoma cells

Allelic deletions of 10q25-26 and 19q13.3-13.4 are the most common genetic alterations in glial tumors. We have identified a balanced t(10;19) reciprocal translocation in the A172 glioblastoma cell line which involves both critical regions on chromosomes 10 and 19. In addition, loss of an entire copy of chromosome 10 has occurred in this cell line suggesting that the translocation event may provide a highly specific critical inactivating event in a gene responsible for tumorigenesis. Positional cloning of this translocation breakpoint resulted in the identification of a novel chromosome 10 gene, WDR11, which is a member of the WD-repeat gene family. The WDR11 gene is ubiquitously expressed, including normal brain and glial tumors. WDR11 is composed of 29 exons distributed over 58 kilobases and oriented towards the telomere. The translocation resulted in deletion of exon 5 and consequently fusion of intron 4 of WDR11 to the 3' untranslated region of a novel member, ZNF320, of the Krüppel-like zinc finger gene family. Since ZNF320 is oriented toward the centromere of chromosome 19, both genes appeared on the same derivative chromosome der(10). The chimeric transcript encodes the WDR11 polypeptide, which is truncated after the second of six WD-repeats. ZNF320 is also expressed in A172 cells, although it is not clear if the translocation affects the expression of the altered gene because of the presence of another unrearranged gene on chromosome 19. We suggest that, because of its localization in a region frequently showing LOH and the observation of inactivation of this gene in glioblastoma cells, WDR11 is a candidate gene for the frequently proposed tumor suppressor gene in 10q25-26 which is involved in tumorigenesis of glial and other tumors showing frequent alterations in the distal 10q region.

Elders' perceptions of formal and informal care: aspects of getting and receiving help for their activities of daily living

A purposive and convenience sample of 16 women and four men receiving informal and formal care for their activities of daily living either at home or institutions in Southeast Washington, USA was interviewed. Qualitative findings related to asking for help, getting and receiving help, interpersonal aspects of receiving help, and met and unmet needs are reported. Some seniors found it more difficult to ask for and accept help and there were gender differences, with men tending to adopt a more logical and pragmatic approach while women viewed receiving help as a loss of independence and an invasion of privacy. Intimacy and nudity were also threats for women. Three styles of adjustment and acceptance were identified within the data and related to positive acceptance, resigned acceptance and passive acceptance. There appeared to be a relationship between independence and control, with elders losing some independence but retaining control through choice, payment and involvement in decision making. Reciprocity was found to bring added value to relationships between care providers and elders, with a rhythm and symmetry developing in relationships where needs were known, anticipated and met. Seniors should be encouraged to plan for their future and to find out about local help and services available to them in advance of their requiring any assistance.

Elders' needs and experiences of receiving formal and informal care for their activities of daily living

Older people living in the community or institutional settings are more likely to require help with their activities of daily living, with women more likely than men to need some help. The interviews in this qualitative study were conducted with a convenience and purposive sample of 20 elders living in Southeast Washington, USA, at home or in institutional settings, receiving informal or formal health care. Findings related to personal and instrumental activities of daily living are reported and include elders' experiences and views relating to the help and assistance they receive. The majority of elders needed help with their instrumental activities of daily living, provided by informal networks, whether living at home or in institutional settings. This help constituted social care. Formal health care with personal activities of daily living was required only by a minority of elders and constituted those with the greatest disability and dependency.

A SNP resource for human chromosome 22: extracting dense clusters of SNPs from the genomic sequence

The recent publication of the complete sequence of human chromosome 22 provides a platform from which to investigate genomic sequence variation. We report the identification and characterization of 12,267 potential variants (SNPs and other small insertions/deletions) of human chromosome 22, discovered in the overlaps of 460 clones used for the chromosome sequencing. We found, on average, 1 potential variant every 1.07 kb and approximately 18% of the potential variants involve insertions/deletions. The SNPs have been positioned both relative to each other, and to genes, predicted genes, repeat sequences, other genetic markers, and the 2730 SNPs previously identified on the chromosome. A subset of the SNPs were verified experimentally using either PCR-RFLP or genomic Invader assays. These experiments confirmed 92% of the potential variants in a panel of 92 individuals. [Details of the SNPs and RFLP assays can be found at http://www.sanger.ac.uk and in dbSNP.]

A transcription map of the minimally deleted region from 13q14 in B-cell chronic lymphocytic leukemia as defined by large scale sequencing of the 650 kb critical region

Extensive analysis of tumors has demonstrated homozygous and heterozygous deletions in chromosome region 13q14.3 in B-cell chronic lymphocytic leukemia (B-CLL), suggesting the site of a tumor suppressor gene. Since previous searches for this gene have not yielded any viable candidates, we now present the sequence of the BACs which span the minimally deleted approximately 650 kb region between markers D13S319 and D13S25. This sequence has allowed us to create the definitive transcription map for the region which reveals 93 ESTs and 12 Unigene clusters in this region. Using gene prediction programs, a further 19 potential genes are also identified. The genes show an asymmetrical distribution throughout the region with most of them clustering at the extreme ends. This sequencing effort provides for the definitive structure of the B-CLL deletion region and the identification of the vast majority of the potential candidate genes. Of all the genes identified, only three have homologies to known genes: two L1 repeat genes and rabbit epididymal protein 52. This 13q14.3 sequence provides the final substrate from which to characterize the B-CLL tumor suppressor gene.

VI. Genome structure and cognitive map of Williams syndrome

Williams syndrome (WMS) is a most compelling model of human cognition, of human genome organization, and of evolution. Due to a deletion in chromosome band 7q11.23, subjects have cardiovascular, connective tissue, and neurodevelopmental deficits. Given the striking peaks and valleys in neurocognition including deficits in visual-spatial and global processing, preserved language and face processing, hypersociability, and heightened affect, the goal of this work has been to identify the genes that are responsible, the cause of the deletion, and its origin in primate evolution. To do this, we have generated an integrated physical, genetic, and transcriptional map of the WMS and flanking regions using multicolor metaphase and interphase fluorescence in situ hybridization (FISH) of bacterial artificial chromosomes (BACs) and P1 artificial chromosomes (PACs), BAC end sequencing, PCR gene marker and microsatellite, large-scale sequencing, cDNA library, and database analyses. The results indicate the genomic organization of the WMS region as two nested duplicated regions flanking a largely single-copy region. There are at least two common deletion breakpoints, one in the centromeric and at least two in the telomeric repeated regions. Clones anchoring the unique to the repeated regions are defined along with three new pseudogene families. Primate studies indicate an evolutionary hot spot for chromosomal inversion in the WMS region. A cognitive phenotypic map of WMS is presented, which combines previous data with five further WMS subjects and three atypical WMS subjects with deletions; two larger (deleted for D7S489L) and one smaller, deleted for genes telomeric to FZD9, through LIMK1, but not WSCR1 or telomeric. The results establish regions and consequent gene candidates for WMS features including mental retardation, hypersociability, and facial features. The approach provides the basis for defining pathways linking genetic underpinnings with the neuroanatomical, functional, and behavioral consequences that result in human cognition.

Effective and ineffective management of incontinence: issues around illness trajectory and health care

In this article, findings from a study that investigated the impact of incontinence on individuals and the impact of effective and ineffective health interventions for the management of incontinence on patient careers and health care are reported. Twenty-seven participants whose incontinence was judged by health professionals as being successfully managed or unsuccessfully managed were interviewed. The participants were 19 women and 8 men (mean age: 61 years). Twenty-two participants experienced urinary incontinence, 4 people experienced both urinary and fecal incontinence, and 1 woman experienced fecal constipation. The findings have been set in the context of the management of chronic conditions and provide illuminating evidence that may be useful when reviewing health care and health services. People who were actively involved with their care and who were involved with decision making felt that their incontinence was being effectively managed. Multiple referrals and the marshaling and targeting of health professionals and services also appeared to be associated with effective management of incontinence.

An approach for obtaining perfect hybridization probes for unknown polyketide synthase genes: a search for the epothilone gene cluster

An approach is described for obtaining 'perfect probes' for type I modular polyketide synthase (PKS) gene clusters that in turn enables the identification of all such gene clusters in a genome. The approach involves sequencing small fragments of a random genomic DNA library containing one or more modular PKS gene clusters, and identifying which fragments emanate from PKS genes. Knowing the approximate sizes of the genome and the target gene cluster, one can predict the the frequency that a PKS gene fragment will be present in the library sequenced. Computer simulations of the approach were applied to the known PKS and non-ribosomal peptide synthetase (NRPS) gene clusters in the Bacillus subtilus genome. The approach was then used to identify PKS gene fragments in a strain of Sorangium cellulosum that produces epothilone. In addition to identifying fragments of the epothilone gene cluster, we obtained 11 unique fragments from other PKS gene clusters; the results suggest that there may be six to eight PKS gene clusters in this organism. In addition, we identified four unique fragments of NRPS genes, demonstrating that the approach is also applicable for identification of these modular gene clusters.

Molecular basis of variant pseudo-hurler polydystrophy (mucolipidosis IIIC)

Mucolipidosis IIIC, or variant pseudo-Hurler polydystrophy, is an autosomal recessive disease of lysosomal hydrolase trafficking. Unlike the related diseases, mucolipidosis II and IIIA, the enzyme affected in mucolipidosis IIIC (N-Acetylglucosamine-1-phosphotransferase [GlcNAc-phosphotransferase]) retains full transferase activity on synthetic substrates but lacks activity on lysosomal hydrolases. Bovine GlcNAc-phosphotransferase has recently been isolated as a multisubunit enzyme with the subunit structure alpha(2)beta(2)gamma(2). We cloned the cDNA for the human gamma-subunit and localized its gene to chromosome 16p. We also showed, in a large multiplex Druze family that exhibits this disorder, that MLIIIC also maps to this chromosomal region. Sequence analysis of the gamma-subunit cDNA in patients from 3 families identified a frameshift mutation, in codon 167 of the gamma subunit, that segregated with the disease, indicating MLIIIC results from mutations in the phosphotransferase gamma-subunit gene. This is to our knowledge the first description of the molecular basis for a human mucolipidosis and suggests that the gamma subunit functions in lysosomal hydrolase recognition.

Prevalence of urinary incontinence and its relationship with health status

A postal survey of two random samples of adult populations within two health authorities in the UK was undertaken during 1994. One health authority had an established continence advisory service (HA1) and the other one did not have a continence advisory service (HA2). A total of 12,529 patients (HA1, 6319; HA2, 6210) were mailed a structured questionnaire and 53% (n = 6139) returned completed questionnaires. A point prevalence of current urinary incontinence of 9% (n = 519, 95% CI, or confidence interval, from 7.9% to 9.3%) was found. A large number of people within the populations had experienced urinary incontinence at some time during their adult years (23%, n = 1427, 95% CI from 22.2% to 24.3%). People who were incontinent had a significantly lower health status than people who were continent (mean scores across all eight domains of the Short Form 36, SF36, P < 0.0001), indicative of greater health and social care needs. The prevalence of urinary incontinence in the adult populations of two communities indicates that it is a sizeable public health and primary healthcare issue.

Comparative sequence analysis of 634 kb of the mouse chromosome 16 region of conserved synteny with the human velocardiofacial syndrome region on chromosome 22q11.2

Mouse genomic DNA sequence extending 634 kb on proximal mouse chromosome 16 was compared to the corresponding human sequence from chromosome 22q11.2. Haploinsufficiency for this region results in velocardiofacial syndrome (VCFS) in humans. The mouse region is rearranged into three conserved blocks relative to human, but gene content and position are highly conserved within these blocks. Examination of the boundaries of one of these blocks suggested that the evolutionary chromosomal rearrangement occurred in the mouse lineage, resulting in inactivation of the mouse orthologue of ZNF74. Sequence analysis identified 21 genes and 15 ESTs. These include 2 novel genes, Srec2 and Cals2, and previously undescribed splice variants of several other genes. Exon discovery was carried out using GRAIL2, MZEF, or comparative analysis across 491 kb of conserved mouse and human sequence. Sequence comparison was highly effective, identifying every gene and nearly every exon without the high frequency of false-positive predictions seen when algorithmic methods were used alone. In combination, these procedures identified every gene with no false-positive predictions. Comparative sequence analysis also revealed regions of extensive conservation among noncoding sequences, accounting for 6% of the sequence. A library of such sequences has been established to form a resource for generalized studies of regulatory and structural elements.

Sequence, structure, and evolution of a complete human olfactory receptor gene cluster

The olfactory receptor (OR) gene cluster on human chromosome 17p13.3 was subjected to mixed shotgun automated DNA sequencing. The resulting 412 kb of genomic sequence include 17 OR coding regions, 6 of which are pseudogenes. Six of the coding regions were discovered only upon genomic sequencing, while the others were previously reported as partial sequences. A comparison of DNA sequences in the vicinity of the OR coding regions revealed a common gene structure with an intronless coding region and at least one upstream noncoding exon. Potential gene control regions including specific pyrimidine:purine tracts and Olf-1 sites have been identified. One of the pseudogenes apparently has evolved into a CpG island. Four extensive CpG islands can be discerned within the cluster, not coupled to specific OR genes. The cluster is flanked at its telomeric end by an unidentified open reading frame (C17orf2) with no significant similarity to any known protein. A high proportion of the cluster sequence (about 60%) belongs to various families of interspersed repetitive elements, with a clear predominance of LINE repeats. The OR genes in the cluster belong to two families and seven subfamilies, which show a relatively high degree of intermixing along the cluster, in seemingly random orientations. This genomic organization may be best accounted for by a complex series of evolutionary events.

Bladder training for urinary incontinence in adults

BACKGROUND

Bladder training is widely used for the treatment of urinary incontinence. It is generally used for the treatment of people with urge incontinence or detrusor instability, although it is also thought that it might be of use for people with mixed incontinence or stress incontinence.

OBJECTIVES

To assess the effects of bladder training for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register up to July 1999. Date of the most recent search: July 1999.

SELECTION CRITERIA

Randomised or quasi-randomised trials of bladder training for the treatment of incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data that were then cross-checked by the third reviewer. All three reviewers assessed trial quality.

MAIN RESULTS

We found seven eligible trials with a total of 259 predominantly female patients with urinary urge incontinence. The quality of trials was variable. Three trials involving 92 women compared bladder training with no bladder training. These tended to favour bladder training but data were available for only a limited number of pre-specified outcomes that varied across the three trials. No data describing long term follow up are available. One trial compared bladder training with drug therapy, but was inconclusive. Another trial compared bladder training with an electronic prompt device. The trial was small and included only 20 women. Data were not presented in a form suitable for quantitative analysis. Two further trials compared bladder training supplemented by drug therapy with bladder training alone. Again, the limited data provided insufficient evidence on which to draw conclusions.

REVIEWER'S CONCLUSIONS

Bladder training may be helpful for the treatment of urinary urge incontinence, but this conclusion can only be tentative, based on the evidence available. There was not enough evidence to show whether drug therapy was better than bladder training or useful as a supplement to it.

Prompted voiding for the management of urinary incontinence in adults

BACKGROUND

Prompted voiding is a behavioural therapy used mainly in North American nursing homes. It aims to improve bladder control for people with or without dementia using verbal prompts and positive reinforcement.

OBJECTIVES

To assess the effects of prompted voiding for the management of urinary incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (to February 2000) and reference lists of relevant articles. We contacted investigators in the field to locate extra studies. Date of the most recent searches: February 2000.

SELECTION CRITERIA

All randomised or quasi-randomised trials which addressed prompted voiding for the management of urinary incontinence. The trials included adult men and women, with or without cognitive impairment, diagnosed as having urinary incontinence as identified by the trialists, either by symptom classification or by urodynamic investigation.

DATA COLLECTION AND ANALYSIS

The identified reports were assessed for eligibility. Two reviewers independently reviewed the selected studies for methodological quality. Data describing six pre-specified outcomes were extracted independently by each reviewer and consensus reached when there was disagreement. Trial investigators were consulted when clarification or further detail was required. A third reviewer was recruited to proof read the review at different stages.

MAIN RESULTS

Five trials were included in the review. These involved 355 elderly people, most of whom were women. One other trial was excluded because no relevant outcome data were reported, and one trial is awaiting assessment. Prompted voiding was compared with no prompted voiding in four trials. The limited evidence suggested that prompted voiding increased self-initiated voiding and decreased incontinent episodes in the short-term. There was no evidence about long-term effects. A single small trial suggested that adding the muscle relaxant, Oxybutinin, reduced the number of incontinent episodes in the short-term: This study used a cross-over design and so did not address long-term effects.

REVIEWER'S CONCLUSIONS

There was insufficient evidence to reach firm conclusions for practice. There was suggestive, although inconclusive, evidence of short-term benefit from prompted voiding and from adding the muscle relaxant, Oxybutinin to prompted voiding.

Lifestyle factors and continence status: comparison of self-report data from a postal survey in England

OBJECTIVE

To compare health and lifestyle factors of people with and without urinary incontinence (UI).

DESIGN

A postal survey was undertaken that represents the first of a 3-stage project designed to evaluate the health interventions of primary health care teams and continence advisory services on patient outcomes related to UI.

SETTING AND SUBJECTS

Two random samples of adult populations (N = 12,529) were included, generated from the family physician patient registers within 2 health authorities in England.

INSTRUMENTS

Data were collected using a structured questionnaire that queried demography, perceived health status, activities of daily living, self-care, and use of local health and social services. Information was also collected on past and present continence status.

METHODS

Structured questionnaires and a cover letter were mailed to the target population. Two reminders were sent to nonresponders to maximize the response rate.

MAIN OUTCOME MEASURES

The main measures relate to factors associated with UI: mobility, sleep, childbirth, smoking, diet, body mass index, and accommodation.

RESULTS

Significantly more women than men had UI (P < .0001). Respondents with UI were older than those who were continent (P < .0001). Women with UI were significantly more likely to have a greater number of pregnancies (P < .0001), were more likely to have given birth to a baby weighing more than 9 lb (P < .01), and to have had more than 4 children (P = .01) compared with women who were continent. People with UI were less likely to be single and more likely to be widowed than those who were continent (P < .0001). People who lived alone and who had UI were also significantly less likely to have a relative or friend that they could depend on for help than those who were continent (P < .001). UI was also found to be significantly associated with impaired mobility (P < .0001) and sleeping difficulties (P < .0001). No meaningful differences were found between diet and UI, although significantly more people with UI had higher mean body mass index, were obese, or reported that they felt too heavy for their height when compared with people who were continent (P < .0001). No association was found in the present study with smoking or ethnicity and UI.

CONCLUSIONS

Key health and lifestyle factors associated with UI included age, gender, childbirth, mobility, sleep patterns, obesity, living alone, and access to help. These factors should be assessed when planning and implementing health care for persons with UI. Attention to these associated factors may prove useful in identifying new cases or people at risk of developing UI when screening people as part of routine health checks. This, in turn, could assist with targeting effective and efficient health care but may also contribute to prevention for some people.

Pressure sore care

Christopher Shiels and Brenda Roe report on a survey into the prevalence and care of pressure sores among older people living in residential care and nursing homes in Liverpool. Setting up appropriate information systems and auditing available pressure-relieving equipment are just two of a number of important recommendations arising from the survey.

Incontinence and sexuality: findings from a qualitative perspective

Incontinence remains a taboo where myths and misconceptions abound. The objectives of this study were to explore the impact of incontinence on an individual's sexuality and to identify the impact of health interventions for the management of incontinence on sexuality. A quota sample of subjects whose incontinence was regarded as being either successfully managed (n = 14) or unsuccessfully managed (n = 12) by continence advisers, community nurses and health visitors from two National Health Service Trusts were interviewed. A further subject whose incontinence was not classified was also interviewed, bringing the total number of interviews to 27. One Trust had an established continence advisory service of some 19 years, while the other Trust did not have a specific continence advisory service and relied upon members of the primary health care team to meet the needs of individuals suffering from incontinence. The qualitative data from this study were analysed using the constant comparative technique and were grouped into themes relating to clothing and appearance, intimacy and caring, management techniques and relationships and life trajectory. This is the first study to have examined management techniques for incontinence and their relationship to an individual's sexuality and therefore has important implications for clinical practice. It has also set the findings of incontinence and sexuality in the context of chronic conditions and their related patient careers and life trajectory.

Help seeking behaviour and health and social services utilisation by people suffering from urinary incontinence

It is estimated that urinary incontinence can effect up to 23% of the population at some time during their adult years, with 9% currently experiencing symptoms. This study found that the majority of sufferers had spoken to or had contacted their GP about their incontinence, and that people currently suffering from incontinence were significantly more likely to have seen their GP within the last month than those who were continent. Help seeking behaviour was also influenced by the severity of incontinence, with people suffering from severe incontinence significantly more likely to have sought help than those with light to moderate incontinence. Two thirds of sufferers who did not seek help were too embarrassed to do so. Significantly more people who were incontinent that did not seek help in a health authority without an established continence service did not know that health services were available, compared with those in a health authority having an established continence service. It is important for health care providers to ensure that the public knows what services are on offer and how to access them. Significantly more incontinence sufferers in the health authority with an established continence service chose not to seek help from a health professional compared with those in the health authority without service, which could indicate there was an element of informed choice in not accessing the services available. Significantly more people who were incontinent than continent required help with their activities of daily living and personal self care. They were also significantly more likely than those who were continent to require formal and informal contacts provided by health services, local authority, the church or voluntary sector. It is important that people suffering from incontinence have their health and social needs assessed so that services can be effectively targeted.

Is there competition between breast-feeding and maternal employment?

Theory suggests that the decision to return to employment after childbirth and the decision to breast-feed may be jointly determined. We estimate models of simultaneous equations for two different aspects of the relationship between maternal employment and breast-feeding using 1993-1994 data from the U.S. Food and Drug Administration's Infant Feeding Practices Study. We first explore the simultaneous duration of breast-feeding and work leave following childbirth. We find that the duration of leave from work significantly affects the duration of breast-feeding, but the effect of breast-feeding on work leave is insignificant. We also estimate models of the daily hours of work and breast-feedings at infant ages 3 months and 6 months postpartum. At both times, the intensity of work effort significantly affects the intensity of breast-feeding, but the reverse is generally not found. Competition clearly exists between work and breast-feeding for many women in our sample.

Sequence-ready physical map of the mouse chromosome 16 region with conserved synteny to the human velocardiofacial syndrome region on 22q11.2

Proximal mouse Chromosome (Chr) 16 shows conserved synteny with human Chrs 16, 8, 22, and 3. The mouse Chr 16/human Chr 22 conserved synteny region includes the DiGeorge/Velocardiofacial syndrome region of human Chr 22q11.2. A physical map of the entire mouse Chr 16/human Chr 22 region of conserved synteny has been constructed to provide a substrate for gene discovery, genomic sequencing, and animal model development. A YAC contig was constructed that extends ca. 5.4 Mb from a region of conserved synteny with human Chr 8 at Prkdc through the region conserved with human Chr 3 at DVL3. Sixty-one markers including 37 genes are mapped with average marker spacing of 90 kb. Physical distance was determined across the 2.6-Mb region from D16Mit74 to Hira with YAC fragmentation. The central region from D16Jhu28 to Igl-C1 was converted into BAC and PAC clones, further refining the physical map and providing sequence-ready template. The gene content and borders of three blocks of conserved linkage between human Chr 22q11.2 mouse Chr 16 are refined.

How big is a drop? A volumetric assay of essential oils

There has been an increase in the use of aromatherapy in nursing, and many issues are now being raised which need addressing in order to maintain professional credibility and safe practice. These issues include: who can safely practise aromatherapy, what qualifications are required to practise, who provides indemnity, and other issues, including the safety and toxicity of essential oils. A small study was undertaken to examine the differences in drop size of bergamot essential oil. Drop size was determined by weighing different manufacturers' essential oil of bergamot and it was found that drop size did differ, resulting in unequal doses of essential oil. It is important to be aware of this, because there are implications for the size of the dose administered in an aromatherapy treatment. This paper raises the issue of standardizing the measurement of essential oils, to ensure that there are no problems regarding safety in their administration.

Telephone or face-to-face interviews?: a decision made on the basis of a pilot study

De Vaus (1991) highlights five main considerations that may be key factors in decisions about whether to use telephone or face-to-face interviews for survey work: response rates, ability to produce representative samples, effects on interview schedule design, quality of responses and implementation problems. De Vaus' discussion of these five issues is outlined at the start of this article. The five issues are then applied to the experiences of researchers conducting a study on continence care. Description and discussion of pilot interviews, which explored both interview modes, are followed by a similar examination of the main study which employed telephone interviews. Ideas in this discussion are supported and challenged by reference to other publications on the subject of telephone and face-to-face interviews. The success of the decision to use telephone interviews in the main study is evaluated and recommendations are made.

Genetic and physical mapping of the Lps locus: identification of the toll-4 receptor as a candidate gene in the critical region

On the basis of 2093 meioses analyzed in two separate intraspecific backcrosses, the location of the mouse Lpsd mutation was circumscribed to a genetic interval 0.9 cM in size. A total of 19 genetic markers that lie in close proximity to the mutation were examined in mapping. Most of these were previously unpublished polymorphic microsatellites, identified by fragmentation of YAC and BAC clones spanning the region of interest. Lpsd was found to be inseparable from the microsatellite marker D4MIT178, and from three novel polymorphic microsatellites identified near D4MIT178. The mutation was confined between two novel microsatellite markers, herein designated "B" and "83.3." B lies centromeric to the mutation, and was separated by four crossovers in a panel of 1600 mice; 83.3 lies distal to the mutation and was separated by three crossovers in a panel of 493 mice. 66 BAC clones and one YAC clone were assembled to cover > 95% of the critical region. Estimates based on pulsed field gel electrophoresis and fluorescence in situ hybridization indicate that the The B-->83.3 interval is about 3.2 Mb in length. A minimal area of zero recombinational distance from Lpsd was also assigned, and found to occupy approximately 1.2 Mb of physical size. To identify gene candidates, nearly 40,000 sequencing runs were performed across the critical region. Selective hybridization and exon trapping were also employed to identify genes throughout the "zero" region. Only a single intact gene was identified within the entire critical region. This gene encodes the Toll-4 receptor, a member of the IL-1 receptor family.