The Forteo Patient Registry linkage to multiple state cancer registries: study design and results from the first 8 years

The Forteo Patient Registry (FPR) aims to estimate the incidence of osteosarcoma in US patients treated with teriparatide. Enrollment began in 2009 and will continue through 2019, with linkage planned through 2024. To date, no incident cases of osteosarcoma have been identified among patients registered in the FPR.

INTRODUCTION

The Forteo Patient Registry (FPR) was established in 2009 to estimate the incidence of osteosarcoma in US patients treated with teriparatide. The objective of this paper is to describe study methods, challenges encountered, and progress to date.

METHODS

The FPR is a prospective US registry designed to link data from participants annually with state cancer registries. Patient enrollment is planned for 10 years (2009-2019) and annual linkage with US state cancer registries for 15 years (2010-2024). All US state cancer registries and DC were invited to participate. Patients are recruited using pre-enrollment materials included in teriparatide device packaging, kits, and brochures distributed by health-care providers; a toll-free number; and a study website. A linkage algorithm is used to match data from enrolled participants with cancer registry data.

RESULTS

For the eighth annual linkage in 2017, information necessary for linkage with 63,270 patients in the FPR was submitted to each of the 42 participating registries. These patients contributed approximately 242,782 person-years of follow-up. A total of 5268 adult osteosarcoma cases diagnosed since January 1, 2009, were available for linkage from participating state cancer registries. To date, no incident cases of osteosarcoma have been identified among patients registered in the FPR.

CONCLUSIONS

Based on the estimated 242,782 person-years of observation as of the eighth annual linkage and projecting current enrollment rate to study end in 2024, it is anticipated that the completed study will be able to detect a fourfold increase in the risk of osteosarcoma if one exists.

The Rise of Urban Growth Coalitions, UK-Style?

The extent to which the period since the mid-1980s has seen the development, in UK towns and cities, of organisations comparable to the urban growth coalitions common to the USA is examined. The focus is particularly on property interests which are the dominant players in US coalitions. An attempt is first made to disaggregate the interests making up the UK property sector into its component parts. The growth-coalition concept, as applied in the USA, is then examined and brief comment made on the extent of its relevance for the contemporary United Kingdom. The third section is an examination of the key contextual factors which have triggered the development of UK variants of growth coalitions. Fourth, recent empirical work is drawn on to examine the part which various property interests have played and the strategic weight which is attached to property development in a number of recent UK public–private partnership organisations. Last, the implications for the process and impact of urban change are examined and it is asked whether the growth-coalition model, and the role of property within it, is likely to be an enduring feature of UK urban economic and political life through the 1990s.

Regional Development Agencies and English Regionalisation: The Question of Accountability

The English Regional Development Agencies (RDAs) are an uneasy halfway house between a standard quango, answerable to Parliament through a Secretary of State, and the regionally accountable development agencies they will become if the government ultimately tackles the democratic deficit in the English regions by creating new, directly elected regional authorities. The accountability arrangements for RDAs are ambiguous as to whether the agenda of the new agencies will primarily reflect the views of their boards and executives, regional stakeholders, or government ministers and departments. The authors put the current debate about RDA accountability into historical perspective and review its main features. They argue that the debate risks ignoring some important factors which affect the success of RDAs if it does not also (a) examine the issue of accountability within and between the broader constellation of organisations whose efforts must underpin the realisation of regional economic strategies, and (b) address a broader debate about the role of regional institutions— elected or not—in encouraging regional economic innovation and development.

What are dental non-attenders' preferences for anxiety management techniques? A cross-sectional study based at a dental access centre

OBJECTIVE

Dental anxiety is a barrier to attendance. Dental non-attenders may seek emergency care and may prefer to receive anxiety management measures for treatment required. Little is known about the preferences of these dental non-attenders for different anxiety management techniques. Understanding such preferences may inform management pathways, improve experiences, alleviate anxieties and encourage a more regular attendance pattern. As such, the aim of this study was to gain a greater understanding of the dental anxiety of patients attending a dental access centre for emergency dental treatment and to ascertain preferences for different anxiety management techniques.

DESIGN

Cross-sectional study involving self-completed questionnaires and clinical observation.

SETTING

NHS Dental Access Centre, York, UK.

SUBJECTS AND METHODS

Two hundred participants not registered with a general dental practitioner, aged 18 years or over, experiencing pain and self-referred were recruited on a consecutive sampling basis. Participants completed a questionnaire eliciting demographic and dental history details, dental anxiety and preferences for dental anxiety management options.

MAIN OUTCOME MEASURES

Correlation of the modified dental anxiety scale with preference for different dental anxiety management techniques.

RESULTS

No significant predictive factors were found that explained preferring local anaesthetic to sedation, or general anaesthesia for restorations or extractions. Those highly anxious were less likely to consider tell-show-do techniques (p=0.001) or watching explanatory videos (p=0.004) to be helpful for overcoming their anxieties than the low or moderate anxiety groups.

CONCLUSIONS

People attending access centres may represent a group who are unwilling to explore non-pharmacological methods to overcome their anxieties. This supports the need for sedation to provide treatment. Future work may include exploring in more depth the thoughts and opinions of this group of patients to improve understanding of their complex dental attitudes. From this, more effective strategies may be developed to encourage regular dental attendance.

The left human speech-processing cortex is thinner but longer than the right

We present histological data from 21 post-mortem, adult human cases that indicate the neocortex on the left planum temporale (secondary auditory cortex) is thinner but longer than that on the right side. The volumes of the left and right regions are approximately equal. Thus, the left planum temporale cortex is long and thin and the right short and thick. The present data fit excellently with previous studies of the volume, surface area, cytoarchitectonics, and neuronal structures of these areas. From these studies we suggest that the hemispheric differences arise from a so-called "balloon model" of cortical development. In this the cortex is extended and stretched by white matter growth. The stretching is greater on the left side, leaving greater distances between neuronal columns and more tangentially (to the pial surface) oriented dendrites on that side. This difference in fine structure can result in more independent activity of individual columns on the left, and could be an anatomical factor in the usual dominance of the left hemisphere for speech perception (Seldon, 1982, 1985).

A reconstruction algorithm for coherent scatter computed tomography based on filtered back-projection

Coherent scatter computed tomography (CSCT) is a reconstructive x-ray imaging technique that yields the spatially resolved coherent-scatter form factor of the investigated object. Reconstruction from coherently scattered x-rays is commonly done using algebraic reconstruction techniques (ART). In this paper, we propose an alternative approach based on filtered back-projection. For the first time, a three-dimensional (3D) filtered back-projection technique using curved 3D back-projection lines is applied to two-dimensional coherent scatter projection data. The proposed algorithm is tested with simulated projection data as well as with projection data acquired with a demonstrator setup similar to a multi-line CT scanner geometry. While yielding comparable image quality as ART reconstruction, the modified 3D filtered back-projection algorithm is about two orders of magnitude faster. In contrast to iterative reconstruction schemes, it has the advantage that subfield-of-view reconstruction becomes feasible. This allows a selective reconstruction of the coherent-scatter form factor for a region of interest. The proposed modified 3D filtered back-projection algorithm is a powerful reconstruction technique to be implemented in a CSCT scanning system. This method gives coherent scatter CT the potential of becoming a competitive modality for medical imaging or nondestructive testing.

Consensus neuropathological diagnosis of common dementia syndromes: testing and standardising the use of multiple diagnostic criteria

The aim of this study was to assess the variation between neuropathologists in the diagnosis of common dementia syndromes when multiple published protocols are applied. Fourteen out of 18 Australian neuropathologists participated in diagnosing 20 cases (16 cases of dementia, 4 age-matched controls) using consensus diagnostic methods. Diagnostic criteria, clinical synopses and slides from multiple brain regions were sent to participants who were asked for case diagnoses. Diagnostic sensitivity, specificity, predictive value, accuracy and variability were determined using percentage agreement and kappa statistics. Using CERAD criteria, there was a high inter-rater agreement for cases with probable and definite Alzheimer's disease but low agreement for cases with possible Alzheimer's disease. Braak staging and the application of criteria for dementia with Lewy bodies also resulted in high inter-rater agreement. There was poor agreement for the diagnosis of frontotemporal dementia and for identifying small vessel disease. Participants rarely diagnosed more than one disease in any case. To improve efficiency when applying multiple diagnostic criteria, several simplifications were proposed and tested on 5 of the original 20 cases. Inter-rater reliability for the diagnosis of Alzheimer's disease and dementia with Lewy bodies significantly improved. Further development of simple and accurate methods to identify small vessel lesions and diagnose frontotemporal dementia is warranted.

Right medial thalamic lesion causes isolated retrograde amnesia

Pervasive retrograde amnesia without anterograde memory impairment has rarely been described as a consequence of circumscribed brain damage. We report this phenomenon in a 33 yr-old, right-handed man (JG) in association with the extension in the right thalamus of a previously small, bilateral thalamic lesion. JG presented with a dense amnesia for autobiographical material more than a few years old, with some sparing of recent memories. Furthermore, he was completely unable to recognise famous people or world events. Many other aspects of semantic knowledge were intact and there was no evidence of general intellectual impairment, executive dysfunction or loss of visual imagery. Magnetic resonance imaging revealed an acute lesion in the right thalamus and two small, symmetrical, bilateral non-acute thalamic lesions. Follow-up neuropsychological assessment indicated a stable pattern of impaired retrograde and spared anterograde memory over 18 months and psychiatric assessments yielded no evidence of confabulation, malingering or other symptoms to suggest psychogenic amnesia. JG's profile indicates that the division of declarative memory into just two categories - episodic and semantic - is inadequate. Rather, his case adds to the growing body evidence to suggest that world knowledge pertaining to people and events is stored or accessed similarly to autobiographical information and differently from other types of more general factual knowledge. We hypothesize that the right mediodorsal thalamic nucleus and immediately surrounding regions comprise the central processing mechanism referred to by McClelland (Revue Neurologique, 150 (1994) 570) and Markowitsch (Brain Research Review, 21 (1995) 117) as responsible for inducing and co-ordinating the recall of these sorts of cortically stored memory engrams.

GTP-dependent segregation of H-ras from lipid rafts is required for biological activity

Different sites of plasma membrane attachment may underlie functional differences between isoforms of Ras. Here we show that palmitoylation and farnesylation targets H-ras to lipid rafts and caveolae, but that the interaction of H-ras with these membrane subdomains is dynamic. GTP-loading redistributes H-ras from rafts into bulk plasma membrane by a mechanism that requires the adjacent hypervariable region of H-ras. Release of H-ras-GTP from rafts is necessary for efficient activation of Raf. By contrast, K-ras is located outside rafts irrespective of bound nucleotide. Our studies identify a novel protein determinant that is required for H-ras function, and show that the GTP/GDP state of H-ras determines its lateral segregation on the plasma membrane.

Psychiatrists' experience and views regarding St John's Wort and 'alternative' treatments

OBJECTIVE

This study aims to ascertain the experience and views of psychiatrists in relation to St John's Wort and alternative treatments generally.

METHOD

A questionnaire was posted to all members of the Royal Australian and New Zealand College of Psychiatrists living in Australia or New Zealand.

RESULTS

Of the 1910 mailed questionnaires, 862 (45%) were returned. Eighty per cent of respondents had patients who had used the herb. Side-effects and drug interactions were reported by 28% and 8% respectively of these psychiatrists. Some adverse events were described as serious. Psychiatrist attitudes about St John's Wort and alternative treatments were positive overall and psychiatrists seemed willing to recommend St John's Wort despite limited evidence of its usefulness.

CONCLUSIONS

Psychiatrists in Australia and New Zealand regularly manage patients who take St John's Wort and a considerable number actually recommend the treatment. However, they also report side-effects and drug interactions. Psychiatrists should routinely enquire about their patients' use of alternative treatments, be mindful of possible side-effects and in particular be aware of the dangers of combining St John's Wort with other psychotropics.

"Make or buy" decisions in the production of health care goods and services: new insights from institutional economics and organizational theory

A central theme of recent health care reforms has been a redefinition of the roles of the state and private providers. With a view to helping governments to arrive at more rational "make or buy" decisions on health care goods and services, we propose a conceptual framework in which a combination of institutional economics and organizational theory is used to examine the core production activities in the health sector. Empirical evidence from actual production modalities is also taken into consideration. We conclude that most inputs for the health sector, with the exception of human resources and knowledge, can be efficiently produced by and bought from the private sector. In the health services of low-income countries most dispersed production forms, e.g. ambulatory care, are already provided by the private sector (non-profit and for-profit). These valuable resources are often ignored by the public sector. The problems of measurability and contestability associated with expensive, complex and concentrated production forms such as hospital care require a stronger regulatory environment and skilled contracting mechanisms before governments can rely on obtaining these services from the private sector. Subsidiary activities within the production process can often be unbundled and outsourced.

Degeneration of anterior thalamic nuclei differentiates alcoholics with amnesia

The specific neural substrate underlying the amnesia in alcoholic Korsakoff's psychosis is poorly defined because of the considerable brain damage found in many non-amnesic alcoholics, particularly those with Wernicke's encephalopathy. Using operational criteria to identify alcoholics with and without Korsakoff's psychosis, we have shown that many of the cortical and subcortical regions involved in the encoding and retrieval of episodic memory are either unaffected (hippocampus) or damaged to the same extent (prefrontal cortex and the cholinergic basal forebrain) in both amnesic and non-amnesic alcoholics. In the present study we analysed the diencephalic regions involved in episodic memory to determine the neural substrate for the amnesia observed in alcoholic Korsakoff's psychosis. The number of neurons in spaced serial sections containing the hypothalamic mamillary nuclei and the anterior and mediodorsal thalamic nuclei was estimated using unbiased stereological techniques. Neurodegeneration of the hypothalamic mamillary nuclei and the mediodorsal thalamic nuclei was substantial in both non-amnesic and amnesic alcoholics with Wernicke's encephalopathy. However, neuronal loss in the anterior thalamic nuclei was found consistently only in alcoholic Korsakoff's psychosis. This is the first demonstration of a differentiating lesion in alcoholic Korsakoff's psychosis and supports previous evidence that degeneration of thalamic relays are important in this memory disorder.

Interactions of c-Raf-1 with phosphatidylserine and 14-3-3

Activation of Raf-1 occurs at the plasma membrane. We recently showed that 14-3-3 must be complexed with Raf-1 for efficient recruitment to the plasma membrane and activation by Ras, but that 14-3-3 is completely displaced from Raf-1 following plasma membrane binding. We show here that the Raf-1 zinc finger is not absolutely required for 14-3-3 binding but is required to stabilize the interaction between Raf-1 and 14-3-3. Incubation of Raf-1 with phosphatidylserine, an inner plasma membrane phospholipid, results in removal of 14-3-3 and an increase in Raf-1 kinase activity, whereas removal of 14-3-3 from Raf-1 using specific phosphopeptides substantially reduces Raf-1 basal kinase activity. Displacement of 14-3-3 from activated Raf-1 by phosphopeptides has no effect on kinase activity if Raf-1 is first removed from solution, but completely eradicates kinase activity of soluble activated Raf-1. These results suggest a mechanism for the removal of 14-3-3 from Raf-1 at the plasma membrane and show that removal of 14-3-3 from Raf-1 has markedly different effects depending on experimental conditions.

Dominant-negative caveolin inhibits H-Ras function by disrupting cholesterol-rich plasma membrane domains

The plasma membrane pits known as caveolae have been implicated both in cholesterol homeostasis and in signal transduction. CavDGV and CavKSY, two dominant-negative amino-terminal truncation mutants of caveolin, the major structural protein of caveolae, significantly inhibited caveola-mediated SV40 infection, and were assayed for effects on Ras function. We find that CavDGV completely blocked Raf activation mediated by H-Ras, but not that mediated by K-Ras. Strikingly, the inhibitory effect of CavDGV on H-Ras signalling was completely reversed by replenishing cell membranes with cholesterol and was mimicked by cyclodextrin treatment, which depletes membrane cholesterol. These results provide a crucial link between the cholesterol-trafficking role of caveolin and its postulated role in signal transduction through cholesterol-rich surface domains. They also provide direct evidence that H-Ras and K-Ras, which are targeted to the plasma membrane by different carboxy-terminal anchors, operate in functionally distinct microdomains of the plasma membrane.

GOS.SP.ASS.'98: an assessment for speech disorders associated with cleft palate and/or velopharyngeal dysfunction (revised)

In 1994 the present authors proposed a speech assessment protocol for speech disorders associated with cleft palate and/or velopharyngeal dysfunction known as GOS.SP.ASS. (Great Ormond Street Speech Assessment). In a recent survey undertaken to review the different speech assessment protocols used in six cleft palate centres in the UK, GOS.SP.ASS. was selected from six protocols as the optimal procedure for clinical and research purposes. The process of identifying an optimal procedure involved analysis of completed forms for each assessment. Analysis of the completed GOS.SP.ASS. forms revealed significant ambiguities in the protocol which led to differences in form completion. This paper describes important revisions to the original GOS.SP.ASS. protocol in order to ensure comparable data from different clinicians. This detailed speech assessment is now complemented by the Cleft Audit Protocol for Speech (CAPS), a tool recommended for clinical audit. As a result of close collaboration in their preparation, the results are directly comparable. In addition, the speech elicitation sentences and the phonetic diagram have been modified.

Active versus passive cleft-type speech characteristics

Cleft palate speech is generally described in terms of nasal resonance, nasal emission and compensatory articulations. A longitudinal study of children at different stages of surgical treatment revealed a distinction between passive and active cleft-type speech characteristics whereby passive characteristics were thought to be the product of structural abnormality or dysfunction and active characteristics were specific articulatory gestures replacing intended consonants. Passive and active patterns of articulation are described and defined in the context of three longitudinal studies of subjects who were at various stages of two different surgical regimes: five bilateral cleft lip and palate (BCLP) subjects aged 1;6-4;6, 12 mixed unilateral cleft lip and palate (UCLP) and BCLP subjects aged 4;6-7;6 and nine mixed UCLP and BCLP subjects aged 9;0-11;0. Reference is also made to data from 12 mixed cleft-type subjects aged 13;0 who had been treated with different surgical timing regimes. Comparison is made between the incidence of active versus passive processes in relation to oral structure. At age 4;6 speech samples taken from BCLP subjects who had been treated with 1-stage versus 2-stage palate repair all evidenced both active and passive processes. The lack of differentiation in speech results irrespective of their current surgical status, i.e. completely repaired palates versus residual cleft of the hard palate, was unexpected. Cleft-type processes in completely repaired subjects might be accounted for by the inevitable anterior defect following repair of a bilateral cleft. Older subjects with structural defects also evidenced more cleft-type processes. The relevance of distinguishing between active and passive processes is underlined by consideration of the effects of structural changes following surgery. The effect of surgery on seven subjects' speech is discussed using the active/passive distinction. Active cleft-type characteristics did not change as a direct result of surgery, whereas passive characteristics were largely eliminated following surgery. A specific distinction is made between active and passive nasal fricatives, with the implication that active nasal fricatives may not be affected by surgical intervention, whereas passive nasal fricatives may be eliminated by surgery. Accurate distinction between active and passive patterns of articulation may serve to identify those cleft-type speech error patterns most likely to respond to surgical intervention. Indications from this study are that active cleft-type characteristics require destabilization in a course of speech and language therapy before the potential benefits of surgery can be properly assessed. An analytical protocol for the interpretation of speech samples is presented and some therapy strategies are proposed for active and passive processes.

The development and role of the Read Codes

Produced and maintained by Britain's National Health Service, the Read Codes are a comprehensive, controlled clinical vocabulary. Here's a look at how the codes evolved, their use in the NHS, and the continual process of aligning the system with the needs of its users.

Exercise before puberty may confer residual benefits in bone density in adulthood: studies in active prepubertal and retired female gymnasts

Exercise during growth may contribute to the prevention of osteoporosis by increasing peak bone mineral density (BMD). However, exercise during puberty may be associated with primary amenorrhea and low peak BMD, while exercise after puberty may be associated with secondary amenorrhea and bone loss. As growth before puberty is relatively sex hormone independent, are the prepubertal years the time during which exercise results in higher BMD? Are any benefits retained in adulthood? We measured areal BMD (g/cm2) by dual-energy X-ray absorptiometry in 45 active prepubertal female gymnasts aged 10.4 +/- 0.3 years (mean +/- SEM), 36 retired female gymnasts aged 25.0 +/- 0.9 years, and 50 controls. The results were expressed as a standardized deviation (SD) or Z score adjusted for bone age in prepubertal gymnasts and chronological age in retired gymnasts. In the cross-sectional analyses, areal BMD in the active prepubertal gymnasts was 0.7-1.9 SD higher at the weight-bearing sites than the predicted mean in controls (p < 0.01). The Z scores increased as the duration of training increased (r = 0.32-0.48, p ranging between <0.04 and <0.002). During 12 months, the increase in areal BMD (g/cm2/year) of the total body, spine, and legs in the active prepubertal gymnasts was 30-85% greater than in prepubertal controls (all p < 0.05). In the retired gymnasts, the areal BMD was 0.5-1.5 SD higher than the predicted mean in controls at all sites, except the skull (p ranging between <0.06 and <0.0001). There was no diminution across the 20 years since retirement (mean 8 +/- 1 years), despite the lower frequency and intensity of exercise. The prepubertal years are likely to be an opportune time for exercise to increase bone density. As residual benefits are maintained into adulthood, exercise before puberty may reduce fracture risk after menopause.

Characterization of 12 microsatellite loci of the human MHC in a panel of reference cell lines

The human genome contains a large number of interspersed microsatellite repeats which exhibit a high degree of polymorphism and are inherited in a Mendelian fashion, making them extremely useful genetic markers. Several microsatellites have been described in the HLA region, but allele nomenclature, a set of broadly distributed controls, and typing methods have not been standardized, which has resulted in discrepant microsatellite data between laboratories. In this report we present a detailed protocol for genotyping microsatellites using a semi-automated fluorescence-based method. Twelve microsatellites within or near the major histocompatibility complex (MHC) were typed in the 10th International Histocompatibility Workshop homozygous typing cell lines (HTCs) and alleles were designated based on size. All loci were sequenced in two HTCs providing some information on the level of complexity of the repeat sequence. A comparison of allele size obtained by genotyping versus that obtained by direct sequencing showed minor discrepancies in some cases, but these were not unexpected given the technical differences in the methodologies. Fluorescence-based typing of microsatellites in the MHC described herein is highly efficient, accurate, and reproducible, and will allow comparison of results between laboratories.

Cleft palate speech dissected: a review of current knowledge and analysis

In this review, normal speech and its development is described and compared with the patterns typical of cleft palate speech. Attention is drawn to the importance of measuring and analysing these factors adequately for research and audit purposes, and the need for agreed parameters for reporting outcomes.

Characteristics of cleft palate speech

In recent years, interest in the nature of cleft palate speech and the influences on speech quality has increased. This overview of contemporary research reveals new perspectives on cleft palate speech development and the phonological consequences of early articulatory constraints. Cleft palate speech is perceived as the result of the synthesis between physical, physiological, cognitive and linguistic development. Developmental influences on cleft palate speech are considered in the context of early vocalisations of cleft and non-cleft children, followed by an examination of the literature on the development of babble, the emergence of early words and consonant development in children born with cleft palate. Speech development is then discussed from a phonological perspective interpreting reported characteristics as 'cleft-type developmental processes', for example, lack of target stabilisation; compensatory articulations; active/passive strategies; and systematic sound preference. Given these influences on speech development the extent to which cleft palate speech should be regarded as an 'articulatory disorder' has been reconsidered. Descriptions and interpretations of nasal resonance, nasal emission, and nasal turbulence are followed by discussion of articulatory errors in place and manner and patterns of change in cleft palate speech. Finally, some of the available evidence on speech in relation to structural imperfections, such as unrepaired clefts, velopharyngeal insufficiency, oro-nasal fistulae, dental and occlusal deviations, and open-mouth posture is summarised briefly. These new perspectives aim to facilitate more effective clinical management and to provide indications for future research.

Intra-amniotic methotrexate versus CO2 laser laparoscopic salpingotomy in the management of tubal ectopic pregnancy--a prospective randomized trial

Tubal pregnancy can be safely and effectively managed by MTX or CO2 laparoscopic salpingotomy techniques. Methotrexate may be superior because of its simplicity, requiring only basic laparoscopic skills, whereas laparoscopic salpingotomy necessitates operative laparoscopic input.

Beta HCG levels after conservative treatment of ectopic pregnancy: is a plateau normal?

In 32 women with unruptured tubal ectopic pregnancies we undertook conservative laparoscopic treatment [local injection of 20 mg methotrexate (n = 18), laser salpingotomy (n = 14)]. The results of serial quantitative beta HCG measurement were followed until either a negative level was reached or until rising levels necessitated alternative/additional therapy. Plateaued values of beta HCG were observed in both the successful (n = 16) and the unsuccessful cases (n = 5). To test the hypothesis that daily variation in the assay could account for some or all of the observed plateaued results in successful cases, the sera were retested serially on the same 'run'. In only one case did laboratory variation account for the observed plateau. The clinical implications of the findings are discussed. We conclude that serially monitored beta HCG results after conservative treatment of ectopic pregnancy may show plateaued values without indicating failure of treatment.

A screening assessment of cleft palate speech (Great Ormond Street Speech Assessment)

This paper presents a comprehensive screening procedure for describing the speech characteristics commonly associated with cleft palate and/or velopharyngeal dysfunction. A unique method of representing the information visually is proposed. The theoretical background and recommendations for clinical application are discussed. This procedure is designed for use by specialist and non-specialist speech and language therapists working in this field. It has been developed primarily with a child population but can be used with all age groups. It provides a structure for assessment, record keeping, report writing and research, thereby facilitating the development of intercentre studies.

Inherited prion disease (PrP lysine 200) in Britain: two case reports

OBJECTIVE

To identify cases of inherited prion diseases in Britain and to assess their phenotypic features.

DESIGN

Screening study of patients suspected clinically to have Creutzfeldt-Jakob disease and other neurodegenerative diseases by prion protein gene analysis.

SETTING

Biochemical research department.

SUBJECTS

Patients suspected to have Creutzfeldt-Jakob disease and other neurodegenerative diseases.

RESULTS

Two patients with symptoms characteristic of sporadic Creutzfeldt-Jakob disease were found to have inherited prion protein disease (PrP lysine 200), with a mutation at codon 200 of the prion protein gene. Both were homozygous at codon 129 of the gene. One patient was a man aged 58 of British descent while the other was of Libyan Jewish origin.

CONCLUSION

Two foci of inherited prion disease are known, among Libyan Jews and in Slovakia. A separate British focus of the disease may also exist. Heterozygosity at codon 129 may lead to reduced penetrance of the mutation.

A comparison of the speech results after early and delayed hard palate closure; a preliminary report

An "early surgery" and a "delayed surgery" group of cleft palate cases' speech has been recorded and judged in two ways. Initially four different listener groups gave their "impressions" of the speech samples followed by the two speech therapist groups assessing specific aspects of speech. For analytical purposes the delayed surgery group was divided into "repaired" and "unrepaired" hard palate groups. The general conclusion was that delaying hard palate surgery may be responsible for the persistence of noticeable abnormal speech patterns until after hard palate repair. However, despite their higher frequency in the "delayed unrepaired" group, errors of tongue placement and airstream direction were common to all groups. The relative influence of maturation, surgery and speech therapy on speech progress has not been considered. It is suggested that a final review of oro-facial growth and speech as each subject reaches 17 years old would give more definitive results. Then the subjects might discuss the relative importance of facial appearance and speech results.

Osteoporotic correlates of alcoholism in young males

A group of 22 white males (ages, 28 to 40 years) with histories of chronic alcohol abuse ranging from 1 to 21 years were evaluated for trabecular bone mineral density in the left femoral neck area. A group of age and weight-matched white males with no history of alcoholism served as controls. All participants completed medical history questionnaires regarding fracture history, dietary habits, medications, and physical activity. Singh femoral trabecular indices also were measured for the alcoholic participants. Analysis of bone mineral data as measured by dual photon absorptiometry revealed no statistically significant reduction in the bone mineral densities of the alcoholic group when compared to the controls. No differences were seen in the areas of the femoral neck, Ward's triangle, and greater trochanter. Duration of alcoholism also was not correlated with the degree of osteopenia. Singh index measurements of right and left femoral heads were compared and revealed no significant differences within individual patients. Left femoral Singh index values averaged 5.5 (range, 4 to 6) for the alcoholic group and were not indicative of decreased bone mineral density. It is concluded from this study that chronic alcoholism associated with heavy smoking most likely has a debilitating effect on the trabecular bone density of white males, yet clinical and radiographic evidence is not widely manifested in men under the age of 40 years.