Current and potential providers of blood pressure self-screening: a mixed methods study in Oxfordshire

OBJECTIVES

To (1) establish the extent of opportunities for members of the public to check their own blood pressure (BP) outside of healthcare consultations (BP self-screening), (2) investigate the reasons for and against hosting such a service and (3) ascertain how BP self-screening data are used in primary care.

DESIGN

A mixed methods, cross-sectional study.

SETTING

Primary care and community locations in Oxfordshire, UK.

PARTICIPANTS

325 sites were surveyed to identify where and in what form BP self-screening services were available. 23 semistructured interviews were then completed with current and potential hosts of BP self-screening services.

RESULTS

18/82 (22%) general practices offered BP self-screening and 68/110 (62%) pharmacies offered professional-led BP screening. There was no evidence of permanent BP self-screening activities in other community settings.Healthcare professionals, managers, community workers and leaders were interviewed. Those in primary care generally felt that practice-based BP self-screening was a beneficial activity that increased the attainment of performance targets although there was variation in its perceived usefulness for patient care. The pharmacists interviewed provided BP checking as a service to the community but were unable to develop self-screening services without a clear business plan. Among potential hosts, barriers to providing a BP self-screening service included a perceived lack of healthcare commissioner and public demand, and a weak-if any-link to their core objectives as an organisation.

CONCLUSIONS

BP self-screening currently occurs in a minority of general practices. Any future development of community BP self-screening programmes will require (1) public promotion and (2) careful consideration of how best to support-and reward-the community hosts who currently perceive little if any benefit.

Exploring the migration decisions of health workers and trainees from Africa: a meta-ethnographic synthesis

The migration of healthcare workers from Africa depletes countries already suffering from substantial staffing shortages and considerable disease burdens. The recruitment of such individuals by high income countries has been condemned by the World Health Organisation. However, understanding the reasons why healthcare workers migrate is essential, in order to attempt to alter migration decisions. We aimed to systematically analyse factors influencing healthcare workers' decisions to migrate from Africa. We systematically searched CINAHL (1980-Nov 2010), Embase (1980-Nov 2010), Global Health (1973-Nov 2010) and Medline (1950-Nov 2010) for qualitative studies of healthcare workers from Africa which specifically explored views about migration. Two reviewers identified articles, extracted data and assessed quality of included studies. Meta-ethnography was used to synthesise new lines of understanding and meaning from the data. The search identified 1203 articles from which we included six studies of healthcare workers trained in seven African countries, namely doctors or medical students (two studies), nurses (three), and pharmacy students (one study). Using meta-ethnographic synthesis we produced six lines of argument relating to the migration decisions of healthcare workers: 1) Struggle to realise unmet material expectations of self, family and society, 2) Strain and emotion, interpersonal discord, and insecurity in workplace, 3) Fear from threats to personal or family safety, in and out of workplace, 4) Absence of adequate professional support and development, 5) Desire for professional prestige and respect, 6) Conviction that hopes and goals for the future will be fulfilled overseas. We conclude that a complex interaction of factors contribute to the migration decisions of healthcare workers from Africa. Some of the factors identified are more amenable to change than others, and addressing these may significantly affect migration decisions of African healthcare workers in the future.

Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial

BACKGROUND

The trial aimed to investigate whether a general practitioner's (GP) letter encouraging participation and a more explicit leaflet explaining how to complete faecal occult blood test (FOBT) included with the England Bowel Cancer Screening Programme invitation materials would improve uptake.

METHODS

A randomised controlled 2 × 2 factorial trial was conducted in the south of England. Overall, 1288 patients registered with 20 GPs invited for screening in October 2009 participated in the trial. Participants were randomised to either a GP's endorsement letter and/or an enhanced information leaflet with their FOBT kit. The primary outcome was verified with return of the test kit within 20 weeks.

RESULTS

Both the GP's endorsement letter and the enhanced procedural leaflet, each increased participation by ∼6% - the GP's letter by 5.8% (95% CI: 4.1-7.8%) and the leaflet by 6.0% (95% CI: 4.3-8.1%). On the basis of the intention-to-treat analysis, the random effects logistic regression model confirmed that there was no important interaction between the two interventions, and estimated an adjusted rate ratio of 1.11 (P=0.038) for the GP's letter and 1.12 (P=0.029) for the leaflet. In the absence of an interaction, an additive effect for receiving both the GP's letter and leaflet (11.8%, 95% CI: 8.5-16%) was confirmed. The per-protocol analysis indicated that the insertion of an electronic GP's signature on the endorsement letter was associated with increased participation (P=0.039).

CONCLUSION

Including both an endorsement letter from each patient's GP and a more explicit procedural leaflet could increase participation in the English Bowel Cancer Screening Programme by ∼10%, a relative improvement of 20% on current performance.

257 DEVELOPMENT OF HEAT-STRESSED OVA MATURED IN THE PRESENCE OF A PROSTAGLANDIN F2ALPHA RECEPTOR ANTAGONIST

Studies in the literature have shown that cumulus–oocyte complexes produce PGF2α, that ova and cumulus cells have PGF2α receptors, and that PGF2α addition to maturing ova, above what would normally be produced, decreases blastocyst development. Because previous studies have shown elevated systemic and tissue levels of PGF2α as a consequence of heat stress, it was hypothesized that detrimental effects of exposing maturing ova to elevated temperatures may be mediated in part through heat-induced increases in PGF2α. To test this hypothesis, cumulus–oocyte complexes were matured at 38.5 or 41.0°C in the presence of a PGF2α receptor antagonist (AL-8810). Preattachment embryo development of AL-8810-treated ova was compared with development of ova matured in media with or without diluent (DMSO added at the same concentration as AL-8810; diluent and developmental controls, respectively), resulting in 6 total treatment combinations. Data were analyzed as a randomized block design (blocking on oocyte collection date) with fixed effects of maturation temperature, AL-8810, and the respective interaction included in the statistical model. In experimental replicates in which the effects of heat stress decreased blastocyst development greater than 10% (n = 14), a significant maturation temperature × AL-8810 interaction was noted when evaluating blastocyst development (P = 0.05). Specifically, when ova were heat stressed during the first 12 h of in vitro maturation, blastocyst development was reduced in developmental and diluent controls (26.2 v. 18.8 and 24.4 v. 19.9, respectively; SEM = 1.6). In contrast, when ova were matured under the same conditions but in the presence of a PGF2α receptor antagonist, the effects of heat stress to reduce blastocyst development after in vitro fertilization were no longer observed (22.5 v. 22.5; SEM = 1.6). When using abattoir-derived ovaries, it is not uncommon to collect, on occasion, ova that are developmentally challenged (i.e. blastocyst development is less than the 20 to 50% expected). In this experiment, this occurred on 5 occasions. Data from these experimental replicates were analyzed and reported separately because previous efforts had shown that the responsiveness of ova to changes in culture environment differs depending on the level of developmental competence. Relevant to this study, addition of AL-8810 to developmentally challenged ova matured under thermoneutral conditions increased cleavage (60.4 v. 55.4%, respectively; P = 0.06) and blastocyst development (17.7 v. 13.7%, respectively; P = 0.07). In summary, data illustrate that developmentally challenged ova, heat-stressed or otherwise, are susceptible to detrimental effects of PGF2α. The ability to increase blastocyst development approaching or exceeding the values expected for competent ova suggests the usefulness of a PGF2α receptor antagonist during in vitro maturation to improve the efficiency of in vitro production procedures.

S. cerevisiae has three pathways for DNA interstrand crosslink repair

Yeast mutants, snm1 (pso2-1), rev3 (pso1-1), and rad51, which display significant sensitivity to interstrand crosslinks (ICLs) have low relative sensitivity to other DNA damaging agents. SNM1, REV3, and RAD51 were disrupted in the same haploid strain, singly and in combination. The double mutants, snm1 Delta rev3 Delta, snm1 Delta rad51 Delta and rev3 Delta rad51 Delta were all more sensitive to ICLs than any of the single mutants, indicating that they are in separate epistasis groups for survival. A triple mutant displayed greater sensitivity to ICLs than any of the double mutants, with one ICL per genome being lethal. Therefore, Saccharomyces cerevisiae appears to have three separate ICL repair pathways, but no more. S-phase delay was not observed after ICL damage introduced by cisplatin (CDDP) or 8-methoxypsoralen (8-MOP) during the G1-phase, in any of the above mutants, or in an isogenic rad14 Delta mutant deficient in nucleotide excision repair. However, the psoralen analog angelicin (monoadduct damage) induced a significant S-phase delay in the rad14 Delta mutant. Thus, normal S-phase in the presence of ICLs does not seem to be due to rapid excision repair. The results also indicate that monoadduct formation by CDDP or 8-MOP at the doses used is not sufficient to delay S-phase in the rad14 Delta mutant. While the sensitivity of a rev3 Delta mutant indicates Pol zeta is needed for optimal ICL repair, isogenic cells deficient in Pol eta (rad30 Delta cells) were not significantly more sensitive to ICL agents than wild-type cells, and have no S-phase delay.

Fetal programming of stress responses

Epidemiological studies have shown that small size at birth is associated with an increased risk of coronary heart disease and its risk factors, including hypertension and Type 2 diabetes.It is suggested that these observations linking low birthweight with disease result from an imbalance between fetal nutrient demand and supply. This imbalance results in metabolic and endocrine adaptations, which benefit the fetus in the short term by reducing fetal growth and increasing fuel availability, but in the longer term they are maladaptive leading to an increased risk of coronary heart disease. Experimental data in animals and recent human observations have suggested that alterations in the set point of the hypothalamic-pituitary-adrenal axis and sympathoadrenal system are important long-term changes that occur in association with reduced fetal growth. These data suggest that the nature and amplitude of the stress response may be determined by intrauterine factors.

Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care

BACKGROUND

Irritable bowel syndrome has a high prevalence. Consensus diagnostic criteria (ROME II) based on symptoms have been established to aid diagnosis. Although coeliac disease can be misdiagnosed as irritable bowel syndrome, no prospective study has been published in which patients with this disorder are investigated for coeliac disease. We aimed to assess the association of coeliac disease with irritable bowel syndrome in patients fulfilling ROME II criteria.

METHODS

We undertook a case-control study at a university hospital. 300 consecutive new patients who fulfilled Rome II criteria for irritable bowel syndrome, and 300 healthy controls (age and sex matched) were investigated for coeliac disease by analysis of serum IgA antigliadin, IgG antigliadin, and endomysial antibodies (EMA). Patients and controls with positive antibody results were offered duodenal biopsy to confirm the possibility of coeliac disease.

FINDINGS

66 patients with irritable bowel syndrome had positive antibody results, of whom 14 had coeliac disease (11 EMA positive, three EMA negative). Nine patients with positive antibody results were lost to follow-up or refused biopsy (only one EMA-positive patient refused biopsy), and 43 had normal duodenal mucosa. Two controls, both of whom were EMA positive, had coeliac disease. Compared with matched controls, irritable bowel syndrome was significantly associated with coeliac disease (p=0.004, odds ratio=7.0 [95% CI 1.7-28.0]).

INTERPRETATION

Patients with irritable bowel syndrome referred to secondary care should be investigated routinely for coeliac disease. With only EMA, three of 14 cases would have been missed.

Prostate specific antigen: biology, biochemistry and available commercial assays

Prostate specific antigen (PSA) is the marker of choice in the management of prostate cancer. However, PSA is not a simple molecule, existing in the serum in five isoforms and a number of molecular configurations and complexes. The elucidation of the biochemistry of PSA has increased the potential use of the marker in the diagnosis of prostate malignancy. This review summarizes the clinical use of PSA in the management of prostate disease and the assays available in the UK. Assay calibration in relation to the World Health Organization 1st International Standard for Prostate Specific Antigen (90:10) has increased conformity between the various commercial assay kits, and the non-equimolar kits have largely been superseded or withdrawn. Special reference is made to evaluations performed on behalf of the Medical Devices Agency of the Department of Health.

General practice research in Australia, 1980-1999

There has been a nearly fivefold increase in the amount of Australian general practice research published in 1990-1999 compared with the previous decade. The university departments of general practice and other university departments have been responsible for most of the research. GPs were involved in at least 60% of all of the research reviewed. Half of the research was found to be clinically pertinent to the front-line GP. The National Health Priority areas, introduced in 1994, were poorly represented, but it is probably too soon for this research to be published. There has also been little research on rural general practice. This review provides a starting point for classifying general practice and primary healthcare research in the future.

Evaluation of a pilot project to use computers in a rural general practice term

In 1998, the Department of General Practice (Faculty of Medicine and Dentistry, University of Western Australia) ran a pilot project to use computers in a sixth year rural general practice term. Students were provided with a laptop computer to take into rural and remote areas throughout Western Australia during their 4-week clinical attachment. An email mailing list was set up for course participants to share experiences and complete set learning activities specifically related to rural general practice. An evaluation of this pilot project found that students felt less isolated on rural attachments, course outcomes were improved and rural preceptors were more involved in the programme. The development of a teaching and learning programme that involves the use of computers in rural general practice for undergraduate students has the potential to improve the quality of their medical education.

Hepatic iron accumulation over time in European starlings (Sturnus vulgaris) fed two levels of iron

European starlings (Sturnus vulgaris) were used as a passerine bird model to examine the effect of dietary iron on the level of hepatic iron in birds. Nestling and fledgling starlings (n = 56) were raised on a controlled-iron diet. When birds maintained constant body weight, they were assigned in pairs to cages, and baseline sampling was performed. Pairs were then assigned to one of two diets: the controlled-iron diet (168 ppm, dry basis) or a high-iron diet (3,035 ppm, dry basis). Dry-matter intake and iron consumption were recorded. Dry-matter intake did not differ between the dietary treatment groups and was stable during treatment periods. Iron intake was higher in the high-iron group (P < 0.05). Birds were euthanized at baseline, 8 wk, and 16 wk. Body, liver, and spleen weights were measured. Hepatic iron and copper concentrations were determined. Body weight did not differ between the two treatment groups or among individuals for the study duration. Liver iron concentration differed over time and between treatment groups. Birds receiving both treatments had similar liver iron content at week 8 (3,107 +/- 228.6 ppm and 3,122 +/- 306.2 ppm high and controlled iron, respectively; P > 0.05), but by week 16, birds consuming the high-iron diet had greater hepatic iron levels than those consuming the controlled-iron diet (5,929 +/- 937.2 ppm and 3,683 +/- 229.5 ppm high and controlled iron, respectively; P < 0.05). Birds on the controlled-iron diet also had higher hepatic iron at 16 wk than at 8 wk. Liver copper decreased over time in all birds regardless of treatment. Results show that both dietary iron level and duration of time influenced hepatic iron storage. The controlled-iron diets still allowed accumulation of hepatic iron in an 8-wk period.

Assessment of latex allergy in a healthcare population: are the available tests valid?

BACKGROUND

Latex allergy can cause serious, preventable work-related health problems in healthcare workers who are a high risk group for this form of allergy. Type I hypersensitivity can produce life-threatening systemic effects, and involves an allergen-specific immunoglobulin (IgE) response to proteins found in latex. The estimated prevalence of latex 'allergy' in healthcare workers varies widely (2.8% - 18%), and studies do not always distinguish between those who are positive in an assay for latex-specific IgE and those with clinical allergy.

OBJECTIVE

To assess the performance of four in-vitro methods and three skin testing methods for detecting latex-specific IgE in a group of UK healthcare workers. Test results were compared with reported clinical symptoms defined by questionnaire.

METHODS

Skin prick testing was carried out on volunteers using three reagents: (a) stallergenes commercial latex extract (Cedex, France); (b) an in-house latex glove extract; and (c) a fresh glove piece. Specific IgE levels were determined using Pharmacia AutocapTM (Uppsala, Sweden), Pharmacia UnicapTM (Uppsala, Sweden), DPC Immulite(R) (Los Angeles, USA) and Hycor HytecTM (Irvine, California, USA) methods. Each volunteer completed a questionnaire detailing latex exposure and allergic history.

RESULTS

In vitro methods for detecting specific IgE to natural rubber latex were positive in 3.6%, to 43.6% of the same population. Skin prick tests positivity varied between 2. 9% and 14.3% with different extracts. From the subjects tested 9.1% reported symptoms which could be consistent with type I allergy, although none had been given a pre-existing diagnosis of latex allergy, and 43.6% of volunteers reported symptoms consistent with type IV hypersensitivity or irritant dermatitis. Contingency tables and chi-squared analysis revealed no correlation between most methods. No correlation was shown between symptoms consistent with type I allergy and any in vitro or skin testing method for latex-specific IgE.

CONCLUSIONS

A wide variation between testing procedures was found, and no method could be correlated with reported symptoms of type I allergy. At least one in vitro specific IgE assay produced a high percentage of positive results at variance with the clinical symptoms in volunteers. A clinical history is essential in establishing type I hypersensitivity to latex and test results should not be used in isolation. The incidence of clinical sensitization may be seriously over-estimated if only laboratory parameters are used.

Saccharomyces cerevisiae lacking Snm1, Rev3 or Rad51 have a normal S-phase but arrest permanently in G2 after cisplatin treatment

The role of Snm1, Rev3 and Rad51 in S-phase after cisplatin (CDDP) DNA treatment has been examined. When isogenic deletion mutants snm1 delta, rev3 delta and rad51 delta were arrested in G1 and treated with doses of CDDP causing significant lethality (<20% survival in the mutant strains), they progressed through S-phase with normal kinetics. The mutants arrested in G2 like wild-type cells, however they did not exit the arrest and reenter the cell cycle. This finding demonstrates that these genes are not required to allow DNA replication in the presence of damage. Therefore, Snm1, Rev3 and Rad51 may act after S to allow repair. At high levels of damage (<40% survival in wild-type cells) S-phase was slowed in a MEC1-dependent fashion. The cross-link incision kinetics of snm1 delta and rev3 delta mutants were also examined; both showed no deficiencies in incision of cross-linked DNA.

Differences in teaching about the acute sore throat within one medical faculty

OBJECTIVES

To examine the consistency of teaching about the acute sore throat in four departments in one medical faculty, and to determine whether there is agreement between what is taught and the evidence-based literature.

DESIGN

Cross-sectional study.

SUBJECTS

71 undergraduates and 15 postgraduate general practice registrars and four lecturers.

RESULTS

Differences were identified in teaching about the diagnostic value of a throat swab, a full blood count and clinical scoring, as well as on the use of penicillin in suspected streptococcal pharyngitis. Only one department based their teaching on the evidence-based literature. No department discussed issues of cost-effectiveness. Half of the students identified discrepancies in the teaching about the sore throat and were initially confused by them.

CONCLUSION

One method of resolving disagreement between teachers from different disciplines is to rely on the evidence-based literature. This type of study can be useful in curricular development and in correcting teaching inconsistencies within a faculty.

Association of chronic urinary symptoms in women and Ureaplasma urealyticum

OBJECTIVES. To determine the incidence of Ureaplasma urealyticum in women experiencing chronic urinary symptoms and to determine whether antibiotic therapy targeting these organisms is effective.

METHODS

Forty-eight consecutive women referred to our academic medical center for chronic voiding symptoms and possible interstitial cystitis underwent urologic evaluation, including culture screening for U. urealyticum and Mycoplasma hominis. Patients with positive cultures were treated with a 1-g dose of azithromycin; persistent infection was treated with 7 days of doxycycline, ofloxacin, or erythromycin. Patients reported symptom severity (0, mild; 3, severe) and voiding frequency before and 6 months after treatment.

RESULTS

Positive cultures were obtained in 23 (48%) of 48 patients; 22 had U. urealyticum and 1 had M. hominis. All had negative cultures after treatment. The mean symptom severity score improved with treatment (2.2 to 0.7, P <0.001), and the mean urinary frequency decreased (9.2 daily to 6.8 daily, P <0.001). Two of the 23 patients experienced no improvement; one had detrusor instability and the other had medically related urinary frequency. Of the 25 patients with negative cultures, interstitial cystitis was established in only 9 (19% of the total sample).

CONCLUSIONS

Although often overlooked or improperly treated, U. urealyticum and M. hominis infections may account for a large proportion of unexplained chronic voiding symptoms. Culture and treatment should be considered before pursuing more costly and invasive tests.

Chlamydia trachomatis infection mimicking testicular malignancy in a young man

A young man with a low risk history for sexually transmitted diseases presented with an apparently longstanding, previously asymptomatic scrotal mass, highly suggestive of testicular malignancy on palpation. Ultrasound sited the lesion in the epididymis. Although there was no evidence of urethritis, chlamydia polymerase chain reaction testing was positive. Tumour markers were negative. Complete clinical and radiological response was achieved after a long course of doxycycline treatment, without surgical exploration of the scrotum, confirming the diagnosis of chlamydial epididymitis.

Chronic obstructive pulmonary disease, with and without alpha-1-antitrypsin deficiency: management practices in the U.K

Alpha-1-antitrypsin deficiency is a common genetic defect associated with the development of severe and rapidly progressive lung disease. This study was undertaken to determine whether respiratory physicians manage patients with alpha-1-antitrypsin (AAT) deficiency differently from patients with chronic obstructive pulmonary disease (COPD) without alpha-1-antitrypsin deficiency. In addition we obtained physicians' views on who should be tested for AAT deficiency. A questionnaire was administered to 88 respiratory physicians based throughout the U.K. (44 in teaching hospitals). The main outcome measures were pulmonary function tests, radiological assessment, frequency of repeat testing, follow-up and screening protocol for alpha-1-antitrypsin deficiency. Subjects with homozygous (PiZ) AAT deficiency were more likely to: 1. have baseline and full pulmonary function testing including dynamic flow rates, static lung volumes, and gas transfer; 2. have more comprehensive assessment with high resolution computed tomography (HRCT) thorax and repeated radiological assessment (with annual chest radiography); 3. be followed-up routinely; and 4. have family members tested for alpha-1-antitrypsin deficiency. Testing remains limited for AAT deficiency and is mainly restricted to young patients with COPD. COPD assessment and management is influenced by the presence of AAT deficiency, which may reflect the poorer prognosis of such patients due to more rapid decline. Assessment and monitoring could be simplified to forced expired manoeuvres, although limited HRCT thorax and tests of gas transfer may prove more sensitive to progression of emphysema. Testing for AAT deficiency in the U.K. remains restricted, which will influence the detection rate for AAT deficiency. A wider policy of testing was advocated by the WHO will detect more patients and also influence our understanding of the natural history of the condition.

Mechanisms of apoptosis in T cells from patients with renal cell carcinoma

Tumors may escape immune recognition and destruction through the induction of apoptosis in activated T lymphocytes. Results from several laboratories suggest that FasL (L/CD95L) expression in tumors may be responsible for this process. In this study of patients with renal cell carcinoma (RCC), we provide evidence for two mechanisms of T-cell apoptosis. One mechanism involves the induction of apoptosis via FasL expression in tumor cells. This is supported by several observations, including the fact that tumor cells in situ as well as cultured cell lines expressed FasL mRNA and protein by a variety of techniques. The FasL in RCC is functional because in coculture experiments, FasL+ tumors induced apoptosis in Fas-sensitive Jurkat T cells and in activated peripheral blood T cells but not in resting peripheral blood T cells. Most importantly, antibody to FasL partially blocked apoptosis of the activated T cells. Moreover, Fas was expressed by T cells derived from the peripheral blood (53% median) and tumor (44.3% median) of RCC patients. Finally, in situ staining for DNA breaks demonstrated apoptosis in a subset of T cells infiltrating renal tumors. These studies also identified a second mechanism of apoptosis in RCC patient peripheral T cells. Whereas these cells did not display DNA breaks when freshly isolated or after culture for 24 h in medium, peripheral blood T cells from RCC patients underwent activation-induced cell death after stimulation with either phorbol 12-myristate 13-acetate/ionomycin or anti-CD3/CD28 antibodies. Apoptosis mediated by exposure to FasL in tumor cells or through T-cell activation may contribute to the failure of RCC patients to develop an effective T-cell-mediated antitumor response.

Epitope expression in nine commercial kits for the determination of anti-thyroid peroxidase (TPO) antibodies

Anti-thyroid peroxidase (TPO) antibodies, from patients with autoimmune disease, bind predominantly to two neighbouring, non-identical, conformational domains referred to as domains A and B. In recent years a number of ELISA assays have been developed for the detection of anti-TPO antibodies, however, considerable variation between the different commercial assay kits has been documented in inter-laboratory surveys (UK NEQAS). This investigation assessed the differences between nine commercial ELISA assays currently available in the UK. The anti-TPO kits varied in terms of their imprecision and accuracy and in the density of coated antigen. Recombinant antigen containing kits demonstrated partial destruction of the B epitope, possibly due to the close proximity of both epitope regions in the recombinant molecule. None of the kits expressed only one epitope although there were differences in the degrees of expression of each epitope. Clinicians should be aware of the variability of the numbers generated, when interpreting test results.

Immunogenicity and efficacy of DNA vaccines encoding influenza A proteins in aged mice

Influenza is a leading cause of morbidity and mortality in older persons. The current influenza vaccine is only modestly successful, in part because of an age-related decline in immunogenicity and also because it induces only type-specified immunity. To overcome this, we evaluated DNA vaccines encoding A/PR8/34 haemagglutinin (HA) and nucleoprotein (NP) in young and aged BALB/c mice. Control mice were given formalin-inactivated A/PR8/34, control DNA, or a non-lethal dose of PR8. Aged mice given HA DNA developed slightly lower anti-HA serum antibodies than young mice; however, both young and aged mice were protected from a homotypic PR8 challenge. Following vaccination with NP DNA, both young and aged mice developed anti-NP bulk cytotoxic T-lymphocyte (CTL) activity and pCTL frequency similar to control animals. When challenged with a low dose of A/HK/68 (H3N2) influenza virus, both young mice and aged mice showed significant protection as measured by inhibition of weight loss. When challenged with a relatively high dose of A/HR/68 (H3N2) influenza virus, however, the anti-NP vaccine only partially protected young mice and failed to protect aged mice. These data demonstrate that DNA-based vaccines are immunogenic in aged animals, but suggest that factors other than the age-related decline in CTL activity also contribute to the increased morbidity and mortality of influenza in the elderly.

The value of prostate specific antigen (PSA) density and free: total PSA ratio in selecting patients with a normal digital rectal examination and intermediate total PSA levels for further investigation

OBJECTIVES

To examine the use of prostate-specific antigen (PSA) density (PSAD) and free to total PSA ratio (f/tPSA) in enhancing the specificity of PSA in the diagnosis of prostate cancer in patients with a total PSA (tPSA) of 4-10 ng/mL and with a normal digital rectal examination (DRE).

PATIENTS AND METHODS

The study comprised 77 consecutive men in whom the fPSA and tPSA levels were obtained before DRE and transrectal ultrasonography-guided sextant prostate biopsy. Prostate cancer was found in 39 patients and the histology was benign in 38. Receiver operator characteristic curves, obtained from all 77 patients, were used to determine the optimal thresholds for PSAD and f/tPSA in detecting cancer. A subset of 28 patients, including seven with prostate cancer, was identified who had a normal DRE and a tPSA of 4-10 ng/mL; PSAD and f/tPSA values were applied at the optimal thresholds to assess their use in identifying those patients with cancer.

RESULTS

When applied to the selected group of 28 patients, the PSAD (threshold 0.15) failed to identify any with prostate cancer. The f/tPSA (threshold 0.12) yielded a sensitivity of 65% and a specificity of 38%, identifying only three of seven patients with cancer. By increasing the threshold to 0.25, six patients were correctly identified, giving a sensitivity of 86%, with a lower specificity of 14%.

CONCLUSIONS

These findings suggest that the neither PSAD nor f/tPSA either significantly reduce the negative biopsy rate or identify patients at greater risk of prostate cancer, particularly when the tPSA is equivocal at 4-10 ng/mL.

Prediction of local recurrence of ductal carcinoma in situ of the breast using five histological classifications: a comparative study with long follow-up

The increased detection of ductal carcinoma in situ (DCIS) by mammographic screening and the more widespread use of breast-conserving surgery have led to a search for histological features associated with the risk of recurrence. In a case control study of 141 patients with long follow-up, we compared the ability of five morphological classifications to predict recurrence after local excision. A significant correlation was not found between recurrence and growth pattern when a traditional classification based on architecture was used nor with necrosis when a scheme based principally on this feature was employed. A correlation was, however, found between recurrence and "differentiation" as defined by nuclear features and cell polarization in a classification recently formulated by the European Pathologists Working Group (EPWG), but this failed to reach statistical significance at the 5% level. A stronger and statistically significant correlation was found between nuclear grade as defined by the EPWG and recurrence when cell polarization was disregarded, using the classification currently employed by the UK National Health Service and European Commission-funded Breast Screening Programmes. This was attributable to a small number of recurring cases being downgraded as a consequence of exhibiting polarized cells. A significant correlation between histology and recurrence was also observed using the Van Nuys classification, which is based on nuclear grade and necrosis. Whether the tumor recurred as in situ or invasive carcinoma was unrelated to histological classification, as was the time course over which it occurred. These findings strongly support the use of nuclear grade to identify cases of DCIS at high risk of recurrence after local excision, but further work is necessary to determine whether nuclear grade or necrosis is more appropriate to subdivide the non-high-grade cases.

Are autoimmune thyroid dysfunction and depression related?

The objective of this study was to examine the relationship between autoimmune thyroid disease and depression in perimenopausal women. Thyroid function [TSH, free T4, and thyroid peroxidase antibodies (TPO-Ab)] and depression (using the Edinburgh Depression Scale) were assessed cross-sectionally together with other determinants of depression. The subjects were 583 randomly selected perimenopausal women (aged 47-54 yr) from a community cohort of 6846 women. The main outcome measures were the occurrence of thyroid dysfunction (abnormal free T4 and/or TSH or elevated levels of TPO-Ab) and the concomitant presence of depression according to the Edinburgh Depression Scale. Neither biochemical thyroid dysfunction nor menopausal status was related to depression. Apart from several psycho-social determinants (the occurrence of a major life event, a previous episode of depression, or financial problems), an elevated level of TPO-Ab (> or = 100 U/mL) was significantly associated with depression (odds ratio, 3.0, 95% confidence interval, 1.3-6.8). We conclude that women with elevated TPO-Ab levels are especially vulnerable to depression, whereas postmenopausal status does not increase the risk of depression.

Ureteropelvic junction obstruction in children. Unique considerations for open operative intervention

The treatment of UPJ obstruction in children should be approached in a fashion that recognizes the differences between children and adults. Radiographic definition of the urinary tract is different in children than in adults because of the size of the child and technical difficulties with instrumentation. Retrograde pyelography, in general, is not necessary in children, although this decision must be individualized. The surgical incision should be chosen based on the size of the child and the unique considerations of individual renal anatomy and pathology, as well as the surgeon's experience. In children, tubeless surgery may be performed with excellent results, however, diversion with nephrostomies and stents may be necessary in selected cases. With attention to technical details and the unique considerations in children, the results of repair of the UPJ should be excellent and reproducible.

Should continent diversion be performed in patients with locally advanced bladder cancer?

OBJECTIVES

To assess the effect of local, regional, and distant recurrence on pouch function in patients with locally advanced bladder cancer treated by cystectomy and continent diversion.

METHODS

A review of 64 consecutive patients undergoing orthotopic (n = 40) or continent cutaneous (n = 24) urinary diversion was performed; 25 patients (39.1%) had locally advanced cancers as defined by deep muscle invasion, extension into perivesical fat, stromal invasion of the prostate, or node-positive disease. Patients were followed at 6-month intervals with physical examination, assessment of voiding function, and computed tomography (CT) scans.

RESULTS

The pelvic recurrence rate was 4.7% in the overall group and 12% in patients with locally advanced disease. In the 39 patients with organ-confined tumors, 34 (87%) are alive without evidence of recurrence and have normal pouch function with a median follow-up of 27 months. Four patients in this group receiving systemic chemotherapy for clinical recurrences have retained normal pouch function until last follow-up or death. In the 25 patients with locally advanced tumors, 15 (60%) are alive without evidence of recurrence and have normal pouch function with a median follow-up of 15 months. Seven patients in this group received a median three cycles of adjuvant chemotherapy, and 4 patients received chemotherapy for clinically evident recurrences. Surgical recovery did not delay the onset of adjuvant therapy in any patient, nor did problems specifically related to the presence of a continent pouch delay any cycle of chemotherapy in those patients treated for recurrent disease in either group. Only 1 patient (1.5%) experienced treatment-related toxicity related to the presence of a continent diversion.

CONCLUSIONS

This experience suggests that the use of orthotopic or continent cutaneous diversions after cystectomy in patients with locally advanced bladder cancer is safe, does not interfere with the delivery of subsequent therapy, and allows most patients to anticipate normal pouch function even in the presence of recurrent disease.

Questioning behaviour in general practice: a pragmatic study

OBJECTIVE

To study the extent to which general practitioners' questioning behaviour in routine practice is likely to encourage the adoption of evidence based medicine.

DESIGN

Self recording of questions by doctors during consultations immediately followed by semistructured interview.

SETTING

Urban Australian general practice.

SUBJECTS

Random sample of 27 general practitioners followed over a half day of consultations.

MAIN OUTCOME MEASURES

Rate of recording of clinical questions about patients' care which doctors would like answered; frequency with which doctors found answers to their questions.

RESULTS

Doctors asked a total of 85 clinical questions, at a rate of 2.4 for every 10 patients seen. They found satisfactory answers to 67 (79%) of these questions. Doctors who worked in small practices (of one or two doctors) had a significantly lower rate of questioning than did those in larger practices (1.6 questions per 10 patients v 3.0 patients, P = 0.049). No other factors were significantly related to rate of questioning.

CONCLUSIONS

These results do not support the view that doctors routinely generate a large number of unanswered clinical questions. It may be necessary to promote questioning behaviour in routine practice if evidence based medicine and other forms of self directed learning are to be successfully introduced.

Serum IgD levels in children under investigation for and with defined immunodeficiency

BACKGROUND

The function and regulation of circulating IgD are unclear. Serum IgD levels were increased in a wide range of immunological diseases but these associations did not give a clue to the regulation of serum IgD production.

METHODS

Serum IgD levels in 131 children with various non-HIV-related immunodeficiency diseases were investigated to examine their relationship with immunoglobulin or antibody production and activation of the immune system. Data from a group of 109 nonimmunodeficient children were also available for comparison.

RESULTS

There was a bimodal distribution of serum IgD levels. In 87 patients IgD levels fell below the limit of detection of 5 IU/ml, while the remainder showed an approximately normal distribution skewed to the right after log transformation. The proportion of children with undetectable IgD levels (< 5 IU/ml) was significantly increased in immunodeficient children (87/131 vs. 28/109, p < 0.001). No difference in the occurrence of immunoglobulin or antibody deficiencies was demonstrated in immunodeficient children with detectable and nondetectable IgD levels. There was a positive correlation of serum IgD with age, serum IgA and IgE, white blood count and CD4+CD25+ lymphocytes but not with other immunoglobulin isotypes or immune activation markers.

CONCLUSION

Determination of serum IgD levels did not seem to be of particular clinical benefit in the investigation of HIV-negative immunodeficient children and serum IgD levels were not associated with the general picture of immune activation. Observed distribution patterns and associations may have implications for the regulation of serum IgD production.

Alpha-1-antitrypsin phenotypes and associated disease patterns in neurological patients

INTRODUCTION

Alpha-1-antitrypsin (AAT) deficiency is usually associated with lung or liver disease. It is often detected as a qualitative reduction of the alpha-1 band on the serum protein electrophoretic pattern.

MATERIAL AND METHODS

We examined the protein electrophoretic pattern in sera of 22980 unselected consecutive patients with neurological disorders and noted a reduced alpha-1 band in 88. Their phenotypes were compared with the clinical disease.

RESULTS

75 patients had a deficient or non-M and 13 the usual MM phenotype. Contrary to in the general population, PiMZ was four times more common than PiMS. Vascular disease was more common in patients with PiMZ while multiple sclerosis significantly more frequent in patients with PiMS than with other phenotypes, including PiMM.

CONCLUSIONS

Other genetic abnormalities have previously been found in AAT associated with multiple sclerosis, but not PiMS. Since PIMS leads to modest reduction of AAT activity, the association may be through other mechanisms than reduced protease activity.

Comparison of monoclonal antibodies for flow cytometric analysis of HLA-B27 antigen

HLA-B27 is an antigen associated with the disease ankylosing spondylitis. Ninety percent of Caucasians with ankylosing spondylitis possess the HLA-B27 antigen. However, only 20% of Caucasians with the HLA-B27 antigen will develop the disease. Defining the presence or absence of the HLA-B27 antigen can be helpful in differentiating ankylosing spondylitis from juvenile rheumatoid arthritis. In this study, we evaluated the application of two monoclonal antibodies (MoAbs), using flow cytometric analysis for the detection of HLA-B27 antigen. After an initial comparison of HLA-B27 analysis by flow cytometry to the standard microlymphocytotoxicity assay, cutoffs were established to differentiate HLA-B27 positive from HLA-B27 negative. One MoAb showed very reliable results with > 99% accuracy in discriminating HLA-B27 positive from HLA-B27 negative samples. Various parameters were investigated to obtain the optimum results and showed that incubation time, reagent lot, and the flow cytometric instrument can affect the results. We concluded that a reliable MoAb and flow cytometry are valuable for the rapid and inexpensive determination of HLA-B27 typing in the clinical setting. However, testing conditions can affect the accuracy of results; therefore, adequate parallel testing in various conditions must be performed in order to establish the proper standards.

Attendance patterns in general practice

OBJECTIVE

To determine the completeness of data acquired previously on the attendance patterns of patients visiting three general practices and the exclusivity of attendance at these practices.

DESIGN

A retrospective comparison of attendance data with data extracted from the Health Insurance Commission database. Three study practices were investigated to give a rough cross-section of general practice in Western Australia.

RESULTS

Eighty-nine per cent of patients and 92% of services recorded in our earlier study were also recorded by the HIC, with 31% of patients also attending another general practice during the six months, mostly only once or twice. However, there was considerable variation between practices in data match and attendance at other practices.

CONCLUSIONS

We found a high level of completeness of data. Sixty-nine per cent of patients attended no other practice during the six months, indicating that doctors in the study practices have some opportunity to provide continuity of care to their patients. The implications for patients' needs and doctors' resources of variations in attendance patterns need to be examined further.

Management of type 2 diabetes in Western Australian metropolitan general practice

The purpose of this study was: (1) to record GP opinions, practices and outcomes for the care of Type 2 Diabetes Mellitus (DM2), (2) compare practice facilities and process of care with a criterion of recommended competent care and (3) determine if there were any differences between vocationally registered and non-vocationally registered GPs. A random sample of 204 metropolitan doctors from 124 practices was selected and an audit performed on 467 of their patient records. GPs pursued good blood sugar control and advocated lifestyle changes before hypoglycaemic drugs. Over 80% regard uncomplicated DM2 as a condition for general practice management. However, only 15% conducted an annual diabetes check, 9% had a diabetic register, 6% a diabetic recall system and 8% used a diabetic health care checklist for monitoring their patients. The most commonly recorded processes of medical audit in the previous 12 months were: blood pressure (94%), duration of diabetes (72%), blood glucose (70%), diet (66%), body weight (56%), HBA1c (52%) and ophthalmoscopy (50%). The least commonly recorded processes of care were body mass index (5%), inspection of the feet (18%), enquiries about vaginitis or impotence (23%). The amount of exercise, alcohol and tobacco was recorded in only 34% of records. Hypoglycaemic drugs were used appropriately but the most commonly used drugs for treating hypertension in DM2 patients were thiazide diuretics and beta-blockers. Vocationally registered (VR) doctors had better records, higher process of care scores and more were willing to participate in the study than non-vocationally registered (NVR) doctors. However, there was no difference in metabolic control between patients from either group. The use of a Diabetic Health Care Checklist would improve diabetes care especially in the search for early complications and in the recording of HBA1c and other metabolic parameters. The drugs commonly used to control hypertension can have adverse effects on glucose and lipid metabolism and should be replaced with glucose and lipid neutral drugs.

Stability of attendance in general practice

Data on the attendances of all patients at three general practices in Western Australia for two 6-month periods 11 months apart were collected as part of a previous study. The present study examined the stability of the attendance patterns of the patients over the two study periods in terms of number of patients, number of visits and diagnoses. The patients who attended in both study periods were classified into four attendance groups: low to low; low to high; high to low; and high to high. The age, sex and diagnoses for each were compared. The results showed that whilst the patient populations remained constant over the two periods, these populations were not comprised of the same patients. Only 45% of those who attended in the first 6 months also attended in the second. Similarly, whilst 8% of patients in each study period were classified as high attenders, only 22% of the high attenders in the first period were also high attenders in the second. The long-term high attenders were older and suffered from chronic diagnoses. The short-term high attenders were found to suffer from more self-limiting diseases and conditions such as depression and pregnancy.

New international reference preparation for proteins in human serum (RPPHS)

Quality-control surveys in recent years, in various parts of the world, have shown poor between-laboratory agreement for measurements of plasma proteins. Despite the existence of international reference materials distributed by the World Health Organization, standards produced by diagnostics manufacturers and professional organizations differ significantly in their ascribed values. The reasons for this are complex but include poor availability of the primary materials, confusion about their use, and the fact that their turbidity on reconstitution precludes their use in modern optical immunoassays. This unfortunate situation led to an important initiative to produce sufficient quantities of a widely available, optically clear secondary reference material for plasma proteins that could be used worldwide by manufacturers, professional organizations, and laboratories. Here we present an overview on how the laboratory community, including manufacturers, clinical laboratories, professional societies, and regulators, has reached what we consider is a successful conclusion to a difficult problem.

New international reference preparation for proteins in human serum (RPPHS)

Quality-control surveys in recent years, in various parts of the world, have shown poor between-laboratory agreement for measurements of plasma proteins. Despite the existence of international reference materials distributed by the World Health Organization, standards produced by diagnostics manufacturers and professional organizations differ significantly in their ascribed values. The reasons for this are complex but include poor availability of the primary materials, confusion about their use, and the fact that their turbidity on reconstitution precludes their use in modern optical immunoassays. This unfortunate situation led to an important initiative to produce sufficient quantities of a widely available, optically clear secondary reference material for plasma proteins that could be used worldwide by manufacturers, professional organizations, and laboratories. Here we present an overview on how the laboratory community, including manufacturers, clinical laboratories, professional societies, and regulators, has reached what we consider is a successful conclusion to a difficult problem.

The significance of elevated basal follicle stimulating hormone in regularly menstruating infertile women

Elevated plasma follicle stimulating hormone (FSH) during the reproductive life is an early manifestation of ovarian ageing. The presence of elevated basal FSH in young, regularly menstruating women may represent a stage of menopausal transition consequent on premature ovarian failure. A total of 48 regularly menstruating, infertile women aged < 40 years, with high FSH and aged-matched controls with normal FSH underwent detailed monitoring of endocrine and follicle growth during one complete menstrual cycle. During the same cycle, detailed immunological screening was performed and the epidemiological features of all subjects were also reviewed. Subjects in the high FSH group had significantly higher basal FSH, luteinizing hormone (LH) and follicular phase LH concentrations. Despite their normal preovulatory oestradiol production, the high FSH group showed significantly slower follicular growth, smaller follicle diameter and lower luteal phase salivary progesterone. All these features have been described in older women during their menopausal transition. In addition, the prevalence of autoimmune antibodies was significantly higher in the high FSH group. This study suggests that infertile women with elevated FSH are in their perimenopause despite having regular ovulatory and apparently normal cycles. An autoimmune basis is suggested as a factor underlying their premature ovarian failure. Further endocrinological and autoimmunological follow-up is recommended.

Immunochemical identity of the 2,3,7,8-tetrachlorodibenzo-p-dioxin- and beta-naphthoflavone-induced cytochrome P-450 arachidonic acid epoxygenases in chick embryo liver: distinction from the omega-hydroxylase and the phenobarbital-induced epoxygenase

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD), beta-naphthoflavone (beta NF), and phenobarbital (PB) cause marked induction of cytochrome P-450 (P-450)-mediated arachidonic acid metabolism in chick embryo liver. We show here that the P-450 arachidonic acid epoxygenases induced by TCDD and beta NF are immunochemically indistinguishable from each other and unrelated to the arachidonic acid epoxygenase induced by PB. On Western blots, IgG from an antiserum against beta NFAA, a 55-kDa P-450 arachidonic acid epoxygenase purified from beta NF-treated chick embryo liver, immunoreacted selectively and to the same extent with a 55-kDa band in liver microsomes from chick embryos treated with TCDD or beta NF. It failed to react with proteins from untreated, solvent-treated, or PB-treated embryos on immunoblots or to immunoinhibit PB-induced arachidonic acid metabolism. Anti-beta NFAA IgG immunoinhibited all arachidonic acid metabolism by reconstituted beta NFAA and formation of arachidonic epoxides (EETs) and monohydroxylated derivatives (HETEs) by microsomes from TCDD- and beta NF-treated livers; it did not inhibit omega-hydroxylation. In contrast, IgG from an antiserum against the major PB-induced chicken P-450s, 2H1 and 2H2, immunoreacted with two major PB-induced P-450s, of 48 and 49 kDa, on Western blots. It also immunoinhibited formation of EETs and HETEs by PB-treated microsomes entirely and omega-hydroxylation by 50%. It failed to react with TCDD- or beta NF-induced P-450s on Western blots or to immunoinhibit TCDD- or beta NF-induced arachidonic acid metabolism. Because other P-450s with which anti-beta NFAA and anti-PB IgG cross-reacted were inactive in arachidonic acid epoxygenation, the findings are consistent with beta NFAA being principally responsible for the epoxygenation induced by TCDD and beta NF and 2H1 and/or 2H2 being responsible for epoxygenation induced by PB. Further, the P-450 arachidonate omega-hydroxylase and the epoxygenase in livers of TCDD- or beta NF-treated embryos are immunochemically unrelated, whereas those in livers of PB-treated embryos may be partly related.

Beta-naphthoflavone induction of a cytochrome P-450 arachidonic acid epoxygenase in chick embryo liver distinct from the aryl hydrocarbon hydroxylase and from phenobarbital-induced arachidonate epoxygenase

Cytochrome P-450-mediated arachidonic acid metabolism in chick embryo liver microsomes was increased by both Ah receptor-dependent (2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and beta-naphthoflavone) and independent (phenobarbital) P-450 inducers. Arachidonic acid epoxides and monohydroxyeicosatetraenoic acids were increased 9-12-fold. omega-1-OH arachidonic acid was also significantly increased by TCDD and beta-naphthoflavone while omega-OH arachidonic acid, the main metabolite in uninduced livers, was decreased by all three agents. The P-450s catalyzing the enhanced arachidonate metabolism in beta-naphthoflavone- and phenobarbital-treated liver were investigated in reconstituted systems containing wholly or partially purified P-450s. beta-Naphthoflavone induced formation of a 55-kDa P-450 selective for arachidonate metabolism and for epoxygenation in particular. This P-450 was purified (beta NFAA). It was found to be distinct from a 54.5-kDa beta-naphthoflavone-induced P-450 catalyzing aryl hydrocarbon hydroxylase and 7-ethoxyresorufin deethylase (designated NF1). Mean turnover numbers for arachidonate epoxygenase, aryl hydrocarbon hydroxylase, and 7-ethoxyresorufin deethylase were 11.2, 0.56, and 0.04, respectively, for reconstituted beta NFAA and 0.33, 11.8, and 2.4 for NF1. beta NFAA and NF1 also differed in chromatography elution characteristics and N-terminal amino acid sequences. Both were low spin, with carbon monoxide binding peaks at 448 nm. The phenobarbital-induced arachidonate epoxygenation was catalyzed by P-450 fractions containing the main 48- and 49-kDa phenobarbital-induced P-450s; fractions in which the 49-kDa P-450 predominated were the most active. Turnover numbers for arachidonic acid epoxygenation were not correlated with those for aminopyrine demethylation or 7-ethoxycoumarin deethylation for P-450s from phenobarbital-treated livers or with aryl hydrocarbon hydroxylase, 7-ethoxyresorufin deethylase, or 7-ethoxycoumarin deethylase for P-450s from beta-naphthoflavone-treated livers. Also, different P-450s catalyzed the epoxygenation and the omega-hydroxylation of arachidonic acid in both beta-naphthoflavone- and phenobarbital-treated livers. The findings support a physiologic role for P-450-induced arachidonate metabolism and provide a basis for a possible link between TCDD's induction of P-450 and alterations of cellular homeostasis.

Free beta human choriogonadotropin in Down's syndrome screening: a multicentre study of its role compared with other biochemical markers

To ascertain the value of maternal serum free beta-human choriogonadotropin subunit measurement in Down's syndrome screening and to compare its effectiveness when screening with a variety of biochemical markers, we have evaluated maternal serum free beta-human choriogonadotropin, total human choriogonadotropin, alpha-fetoprotein and unconjugated oestriol in a large multicentre study of over 2800 unaffected cases and 90 affected cases, the largest collection of Down's cases ever reported. Of all the markers identified to date, free beta-human choriogonadotropin is the marker of choice for use in Down's syndrome screening. When used in early gestation (14-16 weeks) in combination with alpha-fetoprotein and maternal age, it will allow the detection of 77% of Down's cases. A side-by-side comparison with the performance of total human choriogonadotropin shows the superior detection efficiency of free beta-human choriogonadotropin. Unconjugated oestriol adds nothing further to the detection rate compared with the use of alpha-fetoprotein and free beta-human choriogonadotropin alone, and its use results in a 1% increase in false positive rate. We conclude that unconjugated oestriol has no value in Down's screening. The superior detection rate obtained using free beta-human choriogonadotropin is a result of superior detection of Down's cases in women under 30 years old, where the free beta-human choriogonadotropin combination detects 100% more cases than does the total human choriogonadotropin combination.