Outcomes of Degenerative Cervical Myelopathy From The Perspective of Persons Living With the Condition: Findings of a Semistructured Interview Process With Partnered Internet Survey

STUDY DESIGN

Mixed-methods cross-sectional study.

OBJECTIVES

Degenerative cervical myelopathy (DCM) is a common and disabling condition. While classically, assessment and diagnosis has focused on neuromuscular symptoms, many other disabilities have been linked. The aim of this study was to explore the consequences of DCM for those with lived experience, producing a long list to inform the development of a core outcome set for DCM research.

METHODS

A 2-stage process was used: a focus group session of people with DCM (PwCM) and their supporters (n = 8) discussed the impact of DCM. This was used to develop a preliminary list of consequences, which were then placed into a survey of an online community of DCM sufferers (n = 224). Survey participants were asked to tick the consequences that they had experienced and given the opportunity to submit additional. Additional consequences were reviewed by a group of healthcare professionals and PwCM and included if not already represented. Demographic information including disease severity, age, and sex were captured for sampling comparison.

RESULTS

A total of 52 outcomes were identified from the focus group and nominally divided into 2 categories; symptoms (36 outcomes) and handicaps (18 outcomes), and further evaluated using a survey. All outcomes were recognized by at least 5% of respondents. A further 16 outcomes were added following the survey.

CONCLUSIONS

A list of DCM consequences has been defined from the perspective of PwCM. This will now be evaluated as part of AO Spine RECODE-DCM, an international multistakeholder collaboration to establish a core outcome set for research.

Establishing Diagnostic Criteria for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 3]

STUDY DESIGN

Narrative review.

OBJECTIVES

To discuss the importance of establishing diagnostic criteria in Degenerative Cervical Myelopathy (DCM), including factors that must be taken into account and challenges that must be overcome in this process.

METHODS

Literature review summarising current evidence of establishing diagnostic criteria for DCM.

RESULTS

Degenerative Cervical Myelopathy (DCM) is characterised by a degenerative process of the cervical spine resulting in chronic spinal cord dysfunction and subsequent neurological disability. Diagnostic delays lead to progressive neurological decline with associated reduction in quality of life for patients. Surgical decompression may halt neurologic worsening and, in many cases, improves function. Therefore, making a prompt diagnosis of DCM in order to facilitate early surgical intervention is a clinical priority in DCM.

CONCLUSION

There are often extensive delays in the diagnosis of DCM. Presently, no single set of diagnostic criteria exists for DCM, making it challenging for clinicians to make the diagnosis. Earlier diagnosis and subsequent specialist referral could lead to improved patient outcomes using existing treatment modalities.

Prevailing Outcome Themes Reported by People With Degenerative Cervical Myelopathy: Focus Group Study

Background

Degenerative cervical myelopathy (DCM) arises when arthritic changes of the cervical spine cause compression and a progressive injury to the spinal cord. It is common and potentially disabling. People with DCM have among the lowest quality of life scores (Short Form Health Survey–36 item [SF-36]) of chronic disease, although the drivers of the imapact of DCM are not entirely understood. DCM research faces a number of challenges, including the heterogeneous reporting of study data. The AO Spine Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy (RECODE-DCM) project is an international consensus process that aims to improve research efficiency through formation of a core outcome set (COS). A key part of COS development process is organizing outcomes into domains that represent key aspects of the disease. To facilitate this, we sought to qualitatively explore the context and impact of patient-reported outcomes in DCM on study participants.

Objective

The goal of the research was to qualitatively explore the patient-reported outcomes in DCM to improve understanding of patient perspective and assist the organization of outcomes into domains for the consensus process.

Methods

Focus group sessions were hosted in collaboration with Myelopathy.org, a charity and support group for people with DCM. A 40-minute session was audiorecorded and transcribed verbatim. Two authors familiarized themselves with the data and then performed data coding independently. Codes were grouped into themes and a thematic analysis was performed guided by Braun and Clarke’s 6-phase approach. The themes were subsequently reviewed with an independent stakeholder with DCM, assisting in the process of capturing the true context and importance of themes.

Results

Five people with DCM (3 men and 2 women) participated in the focus group session. The median age was 53 years, and the median score on the modified Japanese Orthopaedic Association scale was 11 (interquartile range 9.5-11.5), indicating the participants had moderate to severe DCM. A total of 54 codes were reviewed and grouped into 10 potential themes that captured the impact of the disability on people with DCM: acceptance of symptoms, anticipatory anxiety, coping mechanisms/resilience, feelings of helplessness, financial consequences, lack of recognition, mental health impact, loss of life control, social reclusiveness and isolation, and social stigma.

Conclusions

This qualitative analysis of the perspectives of people with DCM has highlighted a number of prevailing themes currently unmeasured in clinical research or care. The determinants of low quality of life in DCM are currently unknown, and these findings provide a novel and so far, unique perspective. Continued inclusion of online communities and use of targeted digital software will be important in establishing a consensus-based COS for patients with DCM that is inclusive of all relevant stakeholders including people with DCM.

Predictive limitations of spatial interaction models: a non-Gaussian analysis

We present a method to compare spatial interaction models against data based on well known statistical measures that are appropriate for such models and data. We illustrate our approach using a widely used example: commuting data, specifically from the US Census 2000. We find that the radiation model performs significantly worse than an appropriately chosen simple gravity model. Various conclusions are made regarding the development and use of spatial interaction models, including: that spatial interaction models fit badly to data in an absolute sense, that therefore the risk of over-fitting is small and adding additional fitted parameters improves the predictive power of models, and that appropriate choices of input data can improve model fit.

Cord compression defined by MRI is the driving factor behind the decision to operate in Degenerative Cervical Myelopathy despite poor correlation with disease severity

OBJECTIVES

The mainstay treatment for Degenerative Cervical Myelopathy (DCM) is surgical decompression. Not all cases, however, are suitable for surgery. Recent international guidelines advise surgery for moderate to severe disease as well as progressive mild disease. The goal of this study was to examine the factors in current practice that drive the decision to operate in DCM.

STUDY DESIGN

Retrospective cohort study.

METHODS

1 year of cervical spine MRI scans (N = 1123) were reviewed to identify patients with DCM with sufficient clinical documentation (N = 39). Variables at surgical assessment were recorded: age, sex, clinical signs and symptoms of DCM, disease severity, and quantitative MRI measures of cord compression. Bivariate correlations were used to compare each variable with the decision to offer the patient an operation. Subsequent multivariable analysis incorporated all significant bivariate correlations.

RESULTS

Of the 39 patients identified, 25 (64%) were offered an operation. The decision to operate was significantly associated with narrower non-pathological canal and cord diameters as well as cord compression ratio, explaining 50% of the variance. In a multivariable model, only cord compression ratio was significant (p = 0.017). Examination findings, symptoms, functional disability, disease severity, disease progression, and demographic factors were all non-significant.

CONCLUSIONS

Cord compression emerged as the main factor in surgical decision-making prior to the publication of recent guidelines. Newly identified predictors of post-operative outcome were not significantly associated with decision to operate.

A comparison of radiological descriptions of spinal cord compression with quantitative measures, and their role in non-specialist clinical management

INTRODUCTION

Magnetic resonance imaging (MRI) is gold-standard for investigating Degenerative Cervical Myelopathy (DCM), a disabling disease triggered by compression of the spinal cord following degenerative changes of adjacent structures. Quantifiable compression correlates poorly with disease and language describing compression in radiological reports is un-standardised.

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

1) Identify terminology in radiological reporting of cord compression and elucidate relationships between language and quantitative measures 2) Evaluate language's ability to distinguish myelopathic from asymptomatic compression 3) Explore correlations between quantitative or qualitative features and symptom severity 4) Investigate the influence of quantitative and qualitative measures on surgical referrals.

METHODS

From all cervical spine MRIs conducted during one year at a tertiary centre (N = 1123), 166 patients had reported cord compression. For each spinal level deemed compressed by radiologists (N = 218), four quantitative measurements were calculated: 'Maximum Canal Compromise (MCC); 'Maximum Spinal Cord Compression' (MSCC); 'Spinal Canal Occupation Ratio' (SCOR) and 'Compression Ratio' (CR). These were compared to associated radiological reporting terminology.

RESULTS

1) Terminology in radiological reports was varied. Objective measures of compromise correlated poorly with language. "Compressed" was used for more severe cord compromise as measured by MCC (p<0.001), MSCC (p<0.001), and CR (p = 0.002). 2) Greater compromise was seen in cords with a myelopathy diagnosis across MCC (p<0.001); MSCC (p = 0.002) and CR (p<0.001). "Compress" (p<0.001) and "Flatten" (p<0.001) were used more commonly for myelopathy-diagnosis levels. 3) Measurements of cord compromise (MCC: p = 0.304; MSCC: p = 0.217; SCOR: p = 0.503; CR: p = 0.256) and descriptive terms (p = 0.591) did not correlate with i-mJOA score. 4) The only variables affecting spinal surgery referral were increased MSCC (p = 0.001) and use of 'Compressed' (p = 0.045).

CONCLUSIONS

Radiological reporting in DCM is variable and language is not fully predictive of the degree of quantitative cord compression. Additionally, terminology may influence surgical referrals.

Route to diagnosis of degenerative cervical myelopathy in a UK healthcare system: a retrospective cohort study

OBJECTIVES

Degenerative cervical myelopathy (DCM) presents insidiously, making initial diagnosis challenging. Surgery has been shown to prevent further disability but existing spinal cord damage may be permanent. Delays in surgery lead to increased disability and reduced postoperative improvements. Therefore, rapid surgical assessment is key to improving patient outcomes. Unfortunately, diagnosis of DCM in primary care is often delayed. This study aimed to characterise patients with DCM route to diagnosis and surgical assessment as well as to plot disease progression over time.

DESIGN

Retrospective, observational cohort study.

SETTING

Single, tertiary centre using additional clinical records from primary and secondary care centres.

PARTICIPANTS

One year of cervical MRI scans conducted at a tertiary neurosciences centre (n=1123) were screened for cervical cord compression, a corresponding clinical diagnosis of myelopathy and sufficient clinical documentation to plot a route to diagnosis (n=43).

PRIMARY OUTCOME MEASURES

Time to diagnosis from symptom onset, route to diagnosis and disease progression were the primary outcome measures in this study. Disease severity was approximated using a prospectively validated method for inferring modified Japanese Orthopaedic Association (i-mJOA) functional scoring from clinical documentation.

RESULTS

Patients received a referral to secondary care 6.4±7.7 months after symptom onset. Cervical MRI scanning and neurosurgical review occurred 12.5±13.0 and 15.8±13.5 months after symptom onset, respectively. i-mJOA was 16.0±1.7 at primary care assessment and 14.8±2.5 at surgical assessment. 61.0% of patients were offered operations. For those who received surgery, time between onset and surgery was 22.1±13.2 months.

CONCLUSIONS

Route to surgical assessment was heterogeneous and lengthy. Some patients deteriorated during this period. This study highlights the need for a streamlined pathway by which patients with cervical cord compression can receive timely assessment and treatment by a specialist. This would improve outcomes for patients using existing treatments.

Assessment of degenerative cervical myelopathy differs between specialists and may influence time to diagnosis and clinical outcomes

INTRODUCTION

Degenerative Cervical Myelopathy [DCM] often presents with non-specific symptoms and signs. It progresses insidiously and leads to permanent neurological dysfunction. Decompressive surgery can halt disease progression, however significant delays in diagnosis result in increased disability and limit recovery. The nature of early DCM symptoms is unknown, moreover it has been suggested incomplete examination contributes to missed diagnosis. This study examines how DCM is currently assessed, if assessment differs between stages of healthcare, and whether this influences patient management.

STUDY DESIGN

Retrospective cohort study.

METHODS

Cervical MRI scans (N = 1123) at a tertiary neurosciences center, over a single year, were screened for patients with DCM (N = 43). Signs, symptoms, and disease severity of DCM were extracted from patient records. Patients were considered at 3 phases of clinical assessment: primary care, secondary care, and surgical assessment.

RESULTS

Upper limb paraesthesia and urinary dysfunction were consistently the most and least prevalent symptoms respectively. Differences between assessing clinicians were present in the reporting of: limb pain (p<0.005), objective limb weakness (p = 0.01), hyperreflexia (p<0.005), Hoffmann reflex (p<0.005), extensor plantar reflex (p = 0.007), and lower limb spasticity (p<0.005). Pathological reflexes were least frequently assessed by primary care doctors.

CONCLUSION

DCM assessment varies significantly between assessors. Reporting of key features of DCM is especially low in primary care. Incomplete assessment may hinder early diagnosis and referral to spinal surgery.

Abstract P4-15-04: A longitudinal cohort study to identify risk factors for the development of invasive cancer in unresected DCIS

Background: The variable natural history of ductal carcinoma in situ (DCIS) remains poorly understood. Randomized trials of active surveillance versus guideline concordant care are currently underway: the Comparison of Operative to Monitoring and Endocrine Therapy (COMET) trial in the US, LOw Risk dcIS (LORIS) trial in the UK and Low Risk Dcis (LORD) in Europe. Given this context, we examined the outcomes of a contemporary group of women with DCIS who did not undergo initial surgical resection.

Methods: A longitudinal cohort of women diagnosed with DCIS on needle biopsy who did not undergo initial surgical excision for ≥1 year were identified through the Cancer Registry with case note and death certificate review for subsequent outcomes.

Results: Eighty-nine eligible women with DCIS alone diagnosed on needle biopsy (most with 14-gauge core needle biopsy) between 1998 and 2010 were identified. The mean age at diagnosis was 72 years (range 44-94 years) with mean follow-up (diagnosis to death, invasive disease or last review) of 62 months (range 12-180 months). Twenty-nine women (33%) developed histologically proven invasive breast cancer, 28 at the site of the initial DCIS biopsy, after a mean interval of 54 months (range 12-144 months): 14/29 (48%) women originally had high grade DCIS, 10/31 (32%) intermediate grade and 3/17 (18%) low grade DCIS (initial grade not known in 12). Time to detect a diagnosis of invasive breast cancer was associated with initial grade of DCIS (p=0.0016, log-rank test): after mean intervals of 41 months (high grade), 69 months (intermediate grade) and 78 months (low grade) respectively. Younger age was associated with development of invasive disease (p&lt;0.003, Mann-Whitney U-Test). High grade (grade 3) invasive breast cancer exclusively occurred in women with a prior diagnosis of high grade DCIS. Invasion was more frequent in lesions with calcification as the predominant feature than those without (23/50 v. 5/25; p&lt;0.05, Fisher exact test). Forty-four women were prescribed endocrine therapy, use of which was associated with a lower rate of invasive breast cancer (p&lt;0.05). Ultimately 18 women underwent surgery, 17 for invasive cancer. The mean interval from DCIS diagnosis to death was 76 months for those who developed invasive cancer; 48/89 women died, 12 had a certified cause of death as breast cancer.

Conclusion: High grade DCIS, mammographic microcalcification and lack of endocrine therapy were associated with progression to invasion. The findings suggest surgical excision of high grade DCIS should continue but provides support that women with DCIS features which include low grade should be considered for the COMET, LORIS or LORD active surveillance trials.

Citation Format: Maxwell AJ, Clements K, Hilton B, Dodwell DJ, Evans A, Olive K, Pinder SE, Thomas J, Matthew WG, Thompson AM. A longitudinal cohort study to identify risk factors for the development of invasive cancer in unresected DCIS [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-04.

Necrotising pneumonia caused by non-PVL Staphylococcus aureus with 2-year follow-up

Necrotising pneumonia (NP) is a rare but life-threatening complication of pulmonary infection. It is characterised by progressive necrosis of lung parenchyma with cavitating foci evident upon radiological investigation. This article reports the case of a 52-year-old woman, immunocompetent healthcare professional presenting to Accident and Emergency with NP and Staphylococcus aureus septicaemia. The cavitating lesion was not identified on initial chest X-ray leading to a delay in antimicrobial optimisation. However, the patient went on to achieve a full symptomatic recovery in 1 month and complete radiological recovery at 2-year follow-up. Long-term prognosis for adult cases of NP currently remains undocumented. This case serves as the first piece of published evidence documenting full physiological and radiological recovery following appropriate treatment of NP in an immunocompetent adult patient.

Recombinant human luteinizing hormone: a partial physicochemical, biological and immunological characterization

The aim of this study was to partially characterize the glycoform composition of a recombinant human luteinizing hormone preparation (rhLH; Serono), an early version of the material (LHadi) which is currently being assessed for clinical application. Specifically, the charge (pl) and internal carbohydrate complexity of this rhLH was examined and compared with that of an alternative commercially available form of recombinant LH (Crystal Chem) and a pituitary International Reference Preparation (IRP). All preparations were separated by charge by chromatofocusing them on a pH gradient (7-4) using a 4 ml mono-P column is conjunction with a fast performance liquid chromatography system and by complexity of the oligosaccharide structures using concanavalin A (con-A) lectin affinity chromatography. LH in both the unfractionated and fractionated material was assessed by immunoradiometric assay (IRMA, I-LH) and by the in-vitro Leydig cell bioassay (B-LH). Both assays were calibrated against IRP 80/552. The in-vitro biopotency of the preparations was 18187 (Serono rhLH), 12063 (Crystal Chem rhLH) and 6658 (80/552) IU/mg; biological:immunological ratios were 1.14 (80/552), 1.90 (Crystal Chem rhLH) and 1.99 (Serono rhLH). However, similar qualitative data were obtained by both bioassay and immunoradiometric assay following fractionation, with the median pl of the bioactive LH in the preparations being 5.5 (24% > pH 6), 5.52 (18% > pH 6) and 4.97 (0% > pH 6) for the Serono, Crystal Chem and pituitary preparations respectively. Further all three contain < 1% of the complex carbohydrate structures and between 36-44% and 56-63% of the intermediate and simple forms of bioactive LH. In conclusion, the Serono recombinant LH preparation has a higher in-vitro bioactivity and is more basic than the other two preparations although the complexity of its carbohydrate moities appears to be similar.

Oestradiol and immunoreactive inhibin-like secretory patterns following controlled ovarian hyperstimulation with urinary (Metrodin) or recombinant follicle stimulating hormone (Puregon)

Inhibin (and its alpha-subunit) may be of particular value as a marker for follicular development in in-vitro fertilization (IVF) in comparison with the classic follicle stimulating hormone (FSH)-dependent marker oestradiol in patients following pituitary desensitization and treatment with recombinant FSH (rFSH). This preparation lacks luteinizing hormone (LH), which is essential for thecal cell androgen secretion and thus oestradiol production. Our study has assessed oestradiol and immunoreactive inhibin-like secretion following ovarian stimulation with rFSH or a purified urinary FSH preparation (Metrodin) (uFSH). A randomized, assessor-blind study was initiated using patients receiving a single treatment cycle of IVF (using fresh embryos) following pituitary desensitization with intranasal buserelin (500 microg daily) and the i.m. injection of either rFSH (n = 38) or uFSH (n = 17). Ovarian ultrasound examinations were performed and bloods (10 ml) collected prior to FSH treatment and every 1-2 days until ovulation induction with human chorionic gonadotrophin. LH and FSH concentrations were measured by an immunoradiometric assay, and inhibin-like immunoreactivity by a radioimmunoassay and an enzyme-linked immunosorbent assay, both with alpha-subunit specificity. Oestradiol concentration was measured with a coated tube radioimmunoassay. Following desensitization, basal LH, FSH and oestradiol concentrations were measured, as was that of immunoreactive inhibin. Following treatment with either rFSH or uFSH, LH concentrations remained low while FSH concentrations rose to a plateau of 5.6-6.7 IU/l in both groups. In contrast, the concentration of oestradiol was higher (P < 0.05) with rFSH than with uFSH in the last four days of treatment, a pattern that was repeated for inhibin-like immunoreactivity. The change in oestradiol and inhibin concentrations during treatment was approximately 2-fold higher with rFSH. The total number of follicles obtained with rFSH was similar to that with uFSH. However, the number of follicles with a diameter of >/= 15 mm was higher the rFSH group, and there was a concomitant increase in the number of oocytes recovered. Oestradiol concentration and inhibin-like immunoreactivity (determined by either method) were associated with total follicle number and number of follicles >/= 15 mm in diameter, as well as with each other (P < 0.001). When ovarian hormone output was normalized per follicle produced, oestradiol output was higher for rFSH than for uFSH P = 0.04). Inhibin output was clearly higher using rFSH than uFSH. There were seven pregnancies (one miscarriage) with rFSH and two with uFSH. Despite similar concentrations od FSH in patients, rFSH (Puregon) appears to be more potent in vitro in terms of follicular number, ovarian hormone secretion (both concentration and output/follicle) and oocyte recovery. In both groups, LH concentrations of approximately 1.3 IU/l were sufficient to support oestradiol secretion similar to that normally found in IVF programmes using human menopausal gonadotrophin preparations containing large amounts of LH. Despite known problems of specificity with the assays od inhibin, its measurement was of similar value to oestradiol as a marker of follicular development.

In-vitro biopotency and glycoform distribution of recombinant human follicle stimulating hormone (Org 32489), Metrodin and Metrodin-HP

In this study the in-vitro biopotency and glycoform distribution of human recombinant follicle stimulating hormone (FSH, Org 32489) has been assessed. The biopotency of recombinant FSH was studied using animal (rat Sertoli) and human (granulosa-lutein) cell models. Recombinant FSH, as measured in the rat Sertoli cell assay, was more potent than the urinary preparations Metrodin, Metrodin-HP and IS 70/45 with half maximal stimulation (ED50; mean +/- SEM, n > 3) occurring at 2.2 +/- 0.5 IU/I (recombinant FSH), 4.7 +/- 1.1 IU/I (Metrodin), 13.2 +/- 0.7 IU/I (Metrodin-HP) and 6.4 +/- 0.3 IU/I (IS 70/45); the pituitary preparation IRP 83/575 had an ED50 of 10.4 +/- 0.1 IU/I. Using human granulosa-lutein cells, cultured for up to 4 days in the absence of exogenous steroid precursors, recombinant FSH was either without effect (three out of five patients) or inhibited both oestradiol and progesterone secretion. FSH (83/575) was without effect on oestradiol with preparations from any of the patients but slightly stimulated (134 +/- 8%; mean +/- SEM, P < 0.05) progesterone production at the highest dose (80 IU/I). The distribution of FSH isoforms, assessed by polyclonal radioimmunoassay, following chromatofocusing over the ranges pH < 3.5 and pH 3.5-7.0 respectively was recombinant FSH, 12.4 and 87.6%; Metrodin, 19.8 and 80.2%; Metrodin-HP, 50.2 and 49.8%; IS 70/45, 15.0 and 85.0%; IS 83/575, 70.9 and 29.1%. All glycoforms were pI < 7.0 for the five preparations.(ABSTRACT TRUNCATED AT 250 WORDS)

The benefits of business process mapping

We believe that you should view an organization as an integrated organism. Treating parts of this organism without first understanding the whole and how the parts interrelate leads to suboptimal solutions. "Reinventing" an organization requires fresh, objective, new insights. We believe Business Process Analysis and its associated "mapping" is a superior approach to corporate improvements because of: 1. Its emphasis on business processes. 2. Its organization-wide approach. 3. The discipline of requiring process definitions and building the matrices (mapping) required. 4. The involvement of all decision makers. 5. Its usefulness in so many vital areas of management. We know that, given proper top management support and a proper implementation, valid and acceptable improvements will result.

Insulin-like growth factor-I stimulated growth and progesterone production by granulosa-lutein cells. Lack of interaction with physiological concentrations of luteinizing hormone and follicle stimulating hormone

This study examined the effect of physiological concentrations of insulin-like growth factor-I (IGF-I), follicle stimulating hormone (FSH) and luteinizing hormone (LH) alone and in combination on growth and progesterone production by human granulosa-lutein cells. Granulosa-lutein cells were obtained from patients (n > 5) undergoing in-vitro fertilization (IVF) or gamete intra-Fallopian transfer (GIFT) treatment. Cells were cultured for 2 and 4 days in the presence of physiological concentrations of human LH (code 68/40, 5 IU/l), FSH (code 83/575, 20 IU/l), or IGF-I (30 ng/ml) alone and in combination. Medium was changed every 2 days. No change in cell number (relative to each patient's own control) was observed after treatment with FSH or LH alone or in combination at any time. IGF-I alone produced a 117 +/- 8% and 176 +/- 15% (mean +/- SEM, n = 5) increase in cell number after 2 and 4 days respectively. This increase was unaffected by the addition of LH or FSH at any time. Basal progesterone secretion was variable (1633, 975-2409 nmol/l, median and interquartile range, day 2) and decreased with time in culture (564, 375-1089 nmol/l, day 4). After 2 days culture progesterone output increased by 116 +/- 5% of control in response to LH and 153 +/- 13% (mean +/- SEM, n = 5) of control in response to IGF-I. After 4 days, LH and IGF-I stimulated progesterone levels by 279 +/- 52% and 264 +/- 37% (mean +/- SEM, n = 5) respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Business process analysis. Part 2

We are addressing in this three part series, the challenge of making lasting, logical and linked improvements in your organization, aided by fresh, comprehensive and almost certainly unique, new view(s) of your organizational system. Preparing your organization for this type of needed "reinvention" of the organizational system can be better assured if some, preferably all, of the conditions listed in Figure 1 are present. These were introduced and discussed in last month's article. The last item in Figure 1 refers to a "Business Process Map" of the organization. Chances are that you have never encountered this term and only have a vague idea of what is meant by it. Explaining the basis of this evaluative approach is the purpose for this article. Next month, we will show ho useful this insight can be in many strategic decision areas of your business.

Is your organization ready for change?

This article is part of a series written for those who wish to bring about broad, permanent improvements in their organization; those who are "change managers." The subject is change management: Why is change necessary? How to approach it from an overall systems point of view? What are the most important organizational preconditions for any real change to occur? Eight key conditions you should have as a platform for change are listed in this first article. One of these is what Mr. Hilton calls "Business Process Analysis (BPA)." In the second article, this exciting methodology will be discussed. For those of you who prefer the "how to do it" over the theory, this is for you. Then, in November's issue, the benefits of BPA will be shown to have incredible leverage for the change manager and serve as a basis for sound Management Information System Planning, Corporate Restructuring, Process Reengineering, Budgeting, Departmental Productivity Improvement Programs, and Pay-for-Performance Programs. If you fancy yourself a change manager, from CEO to Junior Analyst, you will not want to miss reading this series.

Three-dimensional structure and antigenicity of transmembrane-protein peptides of the human immunodeficiency virus type 1. Effects of a neutralization-escape substitution

A point mutation (Ala-589 to Thr) in the transmembrane protein of the human immunodeficiency virus type 1 (HIV-1) has been shown to decrease the sensitivity of the virus to the neutralizing effect of human HIV-1 specific antibodies [(1990) J. Virol. 64, 3240-3248]. Here 17-residue peptides with the parental and mutant sequences were compared: the parental peptide bound antibodies of sera from HIV-1 infected persons more frequently and with higher affinity than the mutant peptide. However, according to circular dichroism (CD), NMR spectroscopy and molecular modelling the peptides have indistinguishable backbone conformations under a variety of experimental conditions. These techniques showed for both peptides that no ordered helix was present in water solution. However, for both peptides in alcohol-water solutions approximately 60% alpha-helix could be induced. The three-dimensional structures of these peptides provide a basis for understanding how this mutation in the transmembrane protein may affect the interaction with both the outer envelope glycoprotein and with antibodies.