Pediatric Code Blue: How Prepared Are We? A Self-Efficacy Assessment Project

Pediatric advanced life support (PALS) recertification every two years is inadequate to maintain proficiency. The authors hypothesized that a standardized, recurring curriculum may enhance retention of cardiopulmonary resuscitation (CPR) skills. Monthly in situ mock code training and an annual online self-directed learning module were implemented for pediatric intensive care unit nurses, pediatric residents, and respiratory therapists at a women and children's hospital. The in situ mock codes were linked to PALS training self-efficacy (pre- and post-mock code) and feedback related surveys. CPR knowledge was assessed using an online module with pre- and post-tests. A total of 82 in situ mock code surveys and 137 online modules were completed over a 20-month period. Medical knowledge (P < .05 for 7/10 questions) and self-confidence improved (P < .001. Several staff reported a negative impact on their patient care assignments in order to participate in the mock code. However, a significant number of participants (65%) concurred with the benefits of monthly mock codes. The curriculum improved CPR efficacy by improving knowledge-based retention as well as self-confidence in their skills.

Dual candidemia detected by nested polymerase chain reaction in two critically ill children

The use of improved microbiological procedures associated with molecular techniques has increased the identification of Candida bloodstream infections, even if the isolation of more than one species by culture methods remains uncommon. We report the cases of two children presenting with severe gastrointestinal disorders and other risk factors that contribute to Candida infections. In the first patient, C. albicans DNA was initially detected by a nested-amplification and C. tropicalis was found later during hospitalization, while blood cultures were persistently negative. In the second child, there was amplification of C. albicans and C. glabrata DNA in the same samples, but blood cultures yielded only C. albicans. Both patients received antifungal therapy but had unfavorable outcomes. These two cases illustrate that PCR was more successful than culture methods in detecting Candida in the bloodstream of high risk children, and was also able to detect the presence of more than one species in the same patient that might impact therapy when the fungi are resistant to azole compounds.

Tamoxifen down-regulates CaMKII messenger RNA levels in normal human breast tissue

Tamoxifen was proven to reduce the incidence of breast cancer by 49% in women at increased risk of the disease in the Breast Cancer Prevention Trial. In order to identify potential candidates to explain the preventive effect induced by tamoxifen on breast cancer, normal breast tissue obtained from 42 fibroadenoma patients, randomly assigned to receive placebo or tamoxifen, was analyzed by the reverse Northern blot and RT-PCR techniques. The cDNA fragments used on Northern blot membranes were generated by the Human Cancer Genome Project funded by the Ludwig Institute for Cancer Research and FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo, Brazil). Total RNA was obtained from normal breast tissue from patients with clinical, cytological and ultrasound diagnosis of fibroadenoma. After a 50-day treatment with tamoxifen (10 or 20 mg/day) or placebo, normal breast tissue adjacent to the tumor was collected during lumpectomy with local anesthesia. One differentially expressed gene, Calcium/calmodulin-dependent protein kinase II (CaMKII), was found to be down-regulated during TAM treatment. CaMKII is an ubiquitous serine/threonine protein kinase that has been implicated in the diverse effects of hormones utilizing Ca2+ as a second messenger as well as in c-fos activation. These results indicate that the down-regulation of CaMKII induced by TAM might represent alternative or additional mechanisms of the action of this drug on cell cycle control and response to hormones in normal human breast tissue.

Twinfilin is required for actin-dependent developmental processes in Drosophila

The actin cytoskeleton is essential for cellular remodeling and many developmental and morphological processes. Twinfilin is a ubiquitous actin monomer-binding protein whose biological function has remained unclear. We discovered and cloned the Drosophila twinfilin homologue, and show that this protein is ubiquitously expressed in different tissues and developmental stages. A mutation in the twf gene leads to a number of developmental defects, including aberrant bristle morphology. This results from uncontrolled polymerization of actin filaments and misorientation of actin bundles in developing bristles. In wild-type bristles, twinfilin localizes diffusively to cytoplasm and to the ends of actin bundles, and may therefore be involved in localization of actin monomers in cells. We also show that twinfilin and the ADF/cofilin encoding gene twinstar interact genetically in bristle morphogenesis. These results demonstrate that the accurate regulation of size and dynamics of the actin monomer pool by twinfilin is essential for a number of actin-dependent developmental processes in multicellular eukaryotes.

Efficacy of N-acetylcysteine to reduce the effects of aflatoxin B1 intoxication in broiler chickens

N-acetylcysteine (NAC) has been used safely in humans and in other mammals as an antidote against several toxic and carcinogenic agents, including aflatoxin B1 (AFB1). The aim of this study was to evaluate the capability of dietary supplementation with NAC to ameliorate the effects of subacute intoxication with AFB1 in broiler chickens. One hundred twenty male Hubbard 1-d-old chickens were allocated into one of four dietary treatments: 1) control group without treatment, 2) purified AFB1 added to diet (3 mg/kg of feed) for 21 d, 3) NAC (800 mg/kg BW, daily), or 4) AFB1 plus NAC at the same doses as Groups 2 and 3. Broilers treated with AFB1 plus NAC were shown to be partially protected against deleterious effects on BW (57.8%), daily weight gain (49.1%), feed conversion index (21.4%), plasma and hepatic total protein concentration (45.2, 66.7%), plasma alanine aminotransferase (67.4%), hepatic glutathione-S-transferase (18.8%), and reduced glutathione liver concentration (75.0%). In addition, they showed less intense liver fading, friable texture, and microvesicular steatosis. In the kidney, thickening of glomerular basement membrane was also less severe in NAC+AFB1-treated chickens than in AFB1-treated chickens. Our results suggest that NAC provided protection against negative effects on performance, liver and renal damage, and biochemical alterations induced by AFB1 in broiler chickens. Effects of NAC alone on chick performance were also evaluated. Addition of NAC to diet (800 mg/kg BW) did not negatively affect feed consumption, conversion index, or serum chemistry and did not induce structural changes in the liver or kidney.

Principles of patient safety in pediatrics

The American Academy of Pediatrics and its members are committed to improving the health care system to provide the best and safest health care for infants, children, adolescents, and young adults. In response to a 1999 Institute of Medicine report on building a safer health system, a set of principles was established to guide the profession in designing a health care system that maximizes quality of care and minimizes medical errors through identification and resolution. This set of principles provides direction on setting up processes to identify and learn from errors, developing performance standards and expectations for safety, and promoting leadership and knowledge.

Distinct chromosomal deleted regions defining different subsets of head and neck tumors

The aim of this work is detecting the loss of heterozygosity (LOH) and its relationship with the development and progression of head and neck cancer. Matched normal and tumor DNA from 81 patients with head and neck cancer were examined for LOH using six microsatellite repeat markers mapped to chromosomal regions 3p13, 6q13, 9p21, 11p15, 17p13.1, and 17q22. LOH frequency at a locus ranged from 21% to 55%. The highest frequencies were at 3p (41%), 9p (48%), and 17p (54%). Thirty-two of 81 tumor samples showed allelic loss at more than one region. Significant associations were found between LOH at 3p and 9p (P = 0.001), 9p and 11p (P = 0.03), and 9p and 17p (P = 0.007). LOH at 11p was frequent in tumors from the oral cavity (5/17), oropharynx (2/7), and hypopharynx (5/10), but absent in tumors from the larynx (0/11) (P = 0.02), and LOH at 17q was observed in tumors from oral cavity (10/30) and hypopharynx (3/9), but not in tumors from the oropharynx (0/10) or larynx (0/13) (P = 0.003). In addition to that, the occurrence of allelic losses at 9p and 17p strongly correlates to tobacco smoking (P = 0.03 and P = 0.006, respectively) and alcohol intake (P = 0.01 and P = 0.005, respectively). These results suggest that tumors from different sites have different LOH patterns and corroborate with epidemiological data implicating tobacco and alcohol in the etiology of head and neck tumors.

TP53 genetic alterations in head-and-neck carcinomas from Brazil

In this study we investigated the incidence of mutations and loss of heterozygosity (LOH) of the TP53 gene in DNA samples from paired tumor and adjacent normal tissue from 90 patients with untreated squamous-cell carcinoma of the head and neck. Evidence for TP53 mutations were demonstrated in 53% (48/90) of the cases analyzed. All cases were also examined for loss of heterozygosity, using a PCR-based polymorphic marker at TP53. LOH was found in 36 out of 72 (50%) informative cases. Direct sequencing of PCR products was performed in 45 cases with evidence of mutations. The sequencing results revealed the presence of base-substitutions (67%), deletions (29%) and insertions (4%). Of the base-substitutions, 70% were transitions and 30% were transversions. Demographic variables, tumor site, stage (TNM), family history of cancer, lymph-node involvement and histological grade were not important predictors of TP53 mutations. Nor did TP53 genetic alterations correlate with survival status. In conclusion, we show that TP53 genetic alterations are frequent in head-and-neck tumors, but are not associated with clinicopathological variables or disease progression. Our study provides an evaluation of the spectrum of TP53 mutations in the pathogenesis of head-and-neck carcinoma in Brazil.

Nursing role innovations: improved outcomes in a trauma center

Trauma systems operate on the principle that people with severe injuries require special medical capabilities if they are to have their best chance of recovery. However, optimal trauma care is threatened by the problems of inadequate financial reimbursement. This threatens the ability to deliver trauma patient care. A variety of strategies is necessary to continue to provide care. Two specific nursing role innovations provide the opportunity to improve the ability to provide coordinated, efficient, and cost-effective quality care.

TP53 mutations in upper aerodigestive squamous cell carcinomas from a group of Brazilian patients

BACKGROUND

Loss of function of the tumor suppressor gene TP53 contributes to the development of several tumors.

PATIENTS AND METHODS

We screened DNA samples from 47 patients with upper respiratory system squamous cell carcinomas for the presence of TP53 mutations. Exons 4 to 8 of the TP53 gene were amplified by the polymerase chain reaction, and mutations were identified by single-strand conformation polymorphism analysis.

RESULTS

The TP53 mutations were demonstrated in 23 cases (49%). Mutations were distributed as follows: exon 4, 5 cases; exon 5, 4 cases; exon 6, 6 cases; exon 7, 4 cases; and exon 8, 4 cases. Demographic variables, tumor site, stage, family history of cancer, and tobacco smoking were not predictors of TP53 mutations. There was an increasing number of mutations in the more undifferentiated tumors (P = 0.0594).

CONCLUSIONS

These findings suggest that TP53 mutations are associated with tumor differentiation, but not with the risk of lymph node metastasis in the group of patients analyzed.

Estrogen and progesterone receptor mRNA levels in primary breast cancer: association with patient survival and other clinical and tumor features

The relative expression of estrogen receptor (ER) and progesterone receptor (PR) mRNA transcripts was measured in 71 primary breast-cancer biopsies. ER and PR binding activity were estimated in parallel by the dextran-coated-charcoal method. There was a close correlation between the amount of ER mRNA and estradiol binding activity. Tumors from post-menopausal patients contained higher levels of ER mRNA than those from pre-menopausal patients. Northern-blot analysis indicated the presence of a major band of 6.3 kb in all ER mRNA-positive tumors. Some tumors showed, in addition, 3.7- and 2.4-kb transcripts. PR binding activity and overall PR mRNA levels correlated moderately. PR mRNA and ER mRNA were associated. Four PR mRNA species with estimated sizes of 11.4, 4.5, 3.7 and 2.5 kb were detected in 14% of the PR mRNA-positive tumors. The 3.7-kb transcript was detected to varying degrees in all PR mRNA-positive biopsies, accompanied in some tumors by the 2.5-kb species. ER and PR mRNA levels > or = 50 pg/5 micrograms total RNA correlated with prolonged survival of the patients. In addition, high ER mRNA levels were associated with absence or minimal necrosis and vascular invasion together with absence or minimal level of tumor lymphocytic infiltration, but not with age, clinical stage, tumor size or overexpression of c-myc or c-erbB-2 mRNA. PR mRNA was not statistically associated with any of the above clinicopathological features. A bivariate analysis showed that both ER and PR mRNA levels were able to predict overall survival independently of the lymph-node status.

Detailed deletion mapping of chromosome segment 17q12-21 in sporadic breast tumours

Linkage studies have indicated that a gene on chromosome arm 17q, designated BRCA1, confers susceptibility to familial breast and ovarian cancer. To investigate the possible involvement of the BRCA1 gene in sporadic breast cancer we have analysed loss of heterozygosity (LOH) in a panel of 100 sporadic primary breast tumours using 10 PCR-based polymorphic markers from 17q12-21. Allele losses were detected in 40 of 100 tumours informative for at least one of the markers analysed. Of these 40 deleted tumours, 27 showed partial or interstitial loss on 17q. The pattern of LOH in the tumours with partial or interstitial LOH revealed three putative distinct deleted regions on 17q12-21. The first lies on the proximal long arm between D17S250 and THRA1; the second one lies between D17S776 and D17S579, the region containing the BRCA1 gene; and the third is telomeric to D17S733. The most frequently deleted region overlaps with the minimal region containing the BRCA1 gene, suggesting that this gene might also be associated with the development or progression of a proportion of sporadic breast tumours.

Hemodynamic and metabolic effects of cerebral revascularization

Pre- and postoperative positron emission tomography (PET) was performed in six patients undergoing extracranial to intracranial bypass procedures for the treatment of symptomatic extracranial carotid occlusion. The six patients were all men, aged 52 to 68 years. Their symptoms included transient ischemic attacks (five cases), amaurosis fugax (two cases), and completed stroke with good recovery (one case). Positron emission tomography was performed within 4 weeks prior to surgery and between 3 to 6 months postoperatively, using oxygen-15-labeled CO, O2, and CO2 and fluorine-18-labeled fluorodeoxyglucose. Cerebral blood flow (CBF), cerebral blood volume (CBV), cerebral metabolic rates for oxygen and glucose (CMRO2 and CMRGlu), and the oxygen extraction fraction (OEF) were measured in both hemispheres. Preoperatively, compared to five elderly control subjects, patients had increased CBV, a decreased CBF/CBV ratio, and decreased CMRO2, indicating reduced cerebral perfusion pressure and depressed oxygen metabolism. The CBF was decreased in only one patient who had bilateral carotid occlusions; the OEF, CMRGlu, and CMRO2/CMRGlu and CMRGlu/CBF ratios were not significantly different from control measurements. All bypasses were patent and all patients were asymptomatic following surgery. Postoperative PET revealed decreased CBV and an increased CBF/CBV ratio, indicating improved hemodynamic function and oxygen hypometabolism. This was associated with increased CMRO2 in two patients in whom the postoperative OEF was also increased. The CMRGlu and CMRGlu/CBF ratio were increased in five patients. Changes in CBF and the CMRO2/CMRGlu ratio were variable. One patient with preoperative progressive mental deterioration, documented by serial neuropsychological testing and decreasing CBF and CMRO2, had improved postoperative CBF and CMRO2 concomitant with improved neuropsychological functioning. It is concluded that symptomatic carotid occlusion is associated with altered hemodynamic function and oxygen hypometabolism. Cerebral revascularization results in decreased CBV, indicating improved hemodynamic reserve, but does not consistently improve oxygen metabolism.

Effects of rapid mannitol infusion on cerebral blood volume. A positron emission tomographic study in dogs and man

Positron emission tomography was used to study the effect of a rapid infusion of mannitol on cerebral blood volume (CBV) in five dogs and in three human subjects. The ability of mannitol to reduce intracranial pressure (ICP) has always been attributed to its osmotic dehydrating effect. The effects of mannitol infusion include increased osmolality, total blood volume, central venous pressure (CVP), and cerebral blood flow, and decreased hematocrit, hemoglobin concentration, serum sodium level, and viscosity. Mannitol's ability to dilate the cerebral vasculature, either directly or indirectly, and thus to transiently increase ICP, is a subject of controversy. By in vivo labeling of red cells with carbon-11, the authors were able to demonstrate an early increase in CBV in dogs of 20%, 27%, and 23% (mean increase, p less than 0.05) at 1, 2, and 3 minutes, respectively, after an infusion of 20% mannitol (2 gm/kg over a 3-minute period). The animals' muscle blood volume increased by 27% (mean increase, p less than 0.05) 2 minutes after infusion. In the human subjects, lower doses and a longer duration of infusion (1 gm/kg over 4 minutes) resulted in an increase in CBV of 8%, 14% (p less than 0.05), and 10% at 1, 2, and 3 minutes, respectively, after infusion. In dogs, ICP increased by 4 mm Hg (mean increase, p less than 0.05) 1 minute after the infusion, before decreasing sharply. The ICP was not measured in the human subjects. Hematocrit, hemoglobin, sodium, potassium, osmolality, heart rate, mean arterial pressure (MAP), and CVP were measured serially. Results of these measurements, as well as the significant decrease in MAP that occurred after mannitol infusion, are discussed. This study demonstrated that rapid mannitol infusion increases CBV and ICP. The increase in muscle blood volume, in the presence of a decreased MAP and an adequate CVP, suggests that mannitol may have caused vasodilation in these experiments.

The effects of rapid infusions of saline and mannitol on cerebral blood volume and intracranial pressure in dogs

The role of osmotic brain dehydration in the early reduction of intracranial pressure (ICP) following mannitol administration has recently been questioned and a decrease in cerebral blood volume (CBV) proposed as the mechanism of action. To evaluate this hypothesis, relative CBV changes before and after mannitol infusion were determined by collimated gamma counting across the biparietal diameter of the exposed skull in six dogs. Red blood cells were labelled with chromium-51. Cerebral blood volume (CBV), total blood volume (TBV), ICP, mean arterial pressure (MAP), central venous pressure (CVP), haematocrit and osmolality were serially measured after infusions of 10 ml X kg-1 of normal saline (control study) and of 20 per cent mannitol (mannitol study). The solutions were administered over a two-minute period; a 30-minute equilibration period intervened between the saline and mannitol infusions. We demonstrated that the mannitol infusion was associated with significant increases in relative CBV (25 per cent), ICP (7 mmHg), CVP (11 cm H2O), and TBV (50 per cent). MAP declined significantly (14 per cent) after mannitol infusion. The administration of saline, although associated with an increase in TBV (18 per cent), was not associated with any significant change in CBV, ICP, MAP or CVP. The increase in relative CBV persisted for 15 minutes after mannitol infusion, while the ICP returned to control within five minutes and continued to decrease. This study supports the fact that after rapid mannitol infusion, ICP begins to decrease only once the dehydrating effect has counteracted the increase in brain bulk caused by the increase in cerebral blood volume.

[Quantitative double tracer autoradiographic technique for the simultaneous measurement of local cerebral blood flow and local cerebral glucose utilization using 14C-IAP and 18F-FDG]

We have reported a quantitative double tracer autoradiographic technique for the simultaneous measurement of local cerebral blood flow (LCBF) and local cerebral glucose utilization (LCGU) using 14C-IAP and 18F-FDG respectively. Six awake normal rats and 3 left middle cerebral artery (MCA) occluded rats were used for this experiments. A 50-hold greater radioactivity of 18F was administered and the first exposure was done for 2 hours to obtain a 18F image. Three days later (39 half-lives of 18F), a second exposure was done for 5 to 6 days to obtain the 14C image. Tissue concentration of 14C was measured relative to the commercially available 14C-methyl methacrylate standards. 18F standards were prepared in each experiment. Cross contamination of 14C in the first exposure was less than 2% in the normal state and less than 4% even in the uncoupling condition. The values obtained by this methods for LCBF and LCGU agreed closely with those obtained by a single tracer technique previously reported in the literature. The technique outlined in this paper also provided local glucose utilization flow ratio (LGFR) for the first time. LGFR was obtained by dividing the LCGU image by LCBF image and was expressed as percent mumol/ml. The mean LGFR of control rats was 76 +/- 8% mumol/ml. In a MCA occlusion group, LGFR of ischemic cortex increased until 2 to 3 times higher than that of contralateral non-ischemic cortex. Oxygen glucose index image which was obtained from the LCGU and A-V differences of O2 showed that approximately half of the glucose was metabolized anerobically.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversal of acute experimental cerebral vasospasm by calcium antagonism with verapamil

Acute vasospasm of the transclivally exposed basilar artery of anesthetised cats was produced by the subarachnoid injection of platelet-rich plasma (PRP) treated with enough adenosine diphosphate (ADP) to induce platelet aggregation and secretion. Vasorelaxation was produced by the topical application of the calcium antagonist verapamil. Changes in the internal diameter of the basilar artery were determined by measuring the blood column diameter from photomicrographs taken sequentially, at 5 minute intervals, through the operating microscope. Changes in blood vessel diameter are expressed as a plus or minus percentage of the pretreatment diameter. Arterial blood pressure and blood gas values were kept in the physiological range for the cat. The subarachnoid injection of PRP-ADP produced severe constriction of the basilar artery (mean constriction at 5 minutes after injection: -40.7% +/- 2.8 SEM). Platelet-free plasma, ADP alone and Elliott's A solution had no spasmogenic effect when injected into the subarachnoid space. The topical application of the calcium channel blocker verapamil (0.1 mg per kg) 30 minutes after the injection of PRP-ADP, with the basilar artery still in spasm (mean constriction: -23% +/- 3.5 SEM), produced prompt and dramatic vasodilation (mean dilation at 5 minutes after application: +52.7% +/- 18.1 SEM). This spasmolytic effect persisted in a decremental fashion for the 60 minute period of observation, by which time the previously constricted vessel had returned to its normal size. These observations indicate that the platelet fraction of whole blood may be involved in the genesis of acute vasospasm following subarachnoid hemmorrhage and that this phenomenon can be readily reversed by calcium antagonism.

Characteristics of joggers among Japanese men in Hawaii

In a population-based cohort of Japanese American men in Hawaii, the 450 joggers differed from 6,171 nonjoggers in being younger, taller, heavier, and more obese; in having larger vital capacity, higher socioeconomic status, and a higher prevalence of certain electrocardiographic abnormalities; and in being more health conscious as demonstrated by less smoking and a higher frequency of special diets. Blood pressure, serum total cholesterol, hematocrit and high density lipoprotein cholesterol (HDL-C) did not differ significantly between the two groups. Multiple regression analysis showed HDL-C to be inversely related to obesity and cigarettes, and directly related to alcohol consumption but to have no relationship to jogging or age. Temporal analyses suggested that initiation of jogging was followed by a reduction in heart rate, but there was no significant change in other measured parameters. Coronary heart disease (CHD) prevalence was increased in joggers, perhaps because the diagnosis of CHD predisposes to this activity. We conclude that jogging has probably had little impact on the health of this cohort.

A pharmaceutical profile of diabetic patients

Although there have been innumerable studies documenting various aspects of the morbidity caused by diabetes mellitus in the population, very little attention has been paid to patterns of therapeutic management of diabetic patients. The United States Public Health Service Ambulatory Care Data System (USPHS ACDS), a computerized patient information entry and recording system with a complete pharmaceutical record for each patient, was used to compare patterns of pharmaceutical consumption among diabetic patients as opposed to non-diabetic patients in a population of approximately 90,000 individuals. Drug use by diabetics was significantly higher than by non-diabetics. Cardiovascular drug use, in particular, was considerably higher. Substantially higher consumption of anti-lipemic agents, anti-gout drugs, anti-hypertensives, sedatives and tranquilizers was also found in the diabetic population. The higher use of all drugs by diabetics could be partially explained by a demonstrably higher frequency of out-patient visits by diabetics. However this factor alone could not account for very much higher use of certain selective drug groups by the diabetics. In most cases, these selective increases among the diabetics paralleled expected patterns of disease for which those drug groups are prescribed. The investigation of pharmacotherapeutic profiles of the diabetic population adds a new dimension to the epidemiological study of this disease.

Pathologic mechanisms of multifocal choroiditis with retinal detachment after carotid injection of Streptococcus mutans and other bacteria in dogs

Multifocal choroiditis with overlying retinal detachment occurs after carotid injection of certain bacteria in dogs. The ocular lesions occur mainly in the tapetal area of the retina, correlate with microabscesses in the inner choroid and subretinal space, and occasionally occur in the inner retina and anterior uveal tract. The major pathophysiologic factor involved in the dog model of septic choroiditis appears to be embolization of the choriocapillairies by "live" bacteria, which clump and adhere well to tissues. In the dosages used, antibiotics did not prevent or alter the severity of the fundus lesions.

A standardized procedure for quantification of the Ames Salmonella/mammalian-microsome mutagenicity test

Factors determining the precision and variability of the Ames Salmonella test for mutagenicity were investigated. The most important source of variability in the agar-overlay method was nonuniformity in the soft-agar layer thickness. Solution of this problem resulted from application of an agar-leveling table described in this paper. Several other procedural elements also contribute to improved precision, including temperature uniformity during incubation, incubation interval, consistency of plate agar volume, completeness of mixing the soft-agar overlay, peculiarities in the interaction of mutagens and mammalian liver microsomal extract (S9), and methods of storage and controls for tester strains. When these and other effects were well-controlled, variability of the test results was reduced from 200 or 300% to only +/- 10% or less. The significance of the factors affecting precision are discussed and an improved experimental protocol is presented.