Infrared-thermographic screening of the activity and enantioselectivity of enzymes

The infrared radiation caused by the heat of reaction of an enantioselective enzyme-catalyzed transformation can be detected by modern photovoltaic infrared (IR)-thermographic cameras equipped with focal-plane array detectors. Specifically, in the lipase-catalyzed enantioselective acylation of racemic 1-phenylethanol, the (R)- and (S)-substrates are allowed to react separately in the wells of microtiter plates, the (R)-alcohol showing hot spots in the IR-thermographic images. Thus, highly enantioselective enzymes can be identified at kinetic resolution.

Comparison of clinical performance, histology and single-fiber contractility in free neurovascular muscle flaps

The aim of this study was to obtain further insights about muscle regeneration processes in free neurovascular flaps. In cases of insufficient functional return of muscle strength, several factors, such as diminished axonal ingrowth, fatty degeneration, or connective tissue proliferation are discussed. In the study, free neurovascular latissimus dorsi (LD) flaps were examined after a regeneration period of 2 to 6 years. Clinical function (M1 to M4) and histopathologic characteristics of the muscle grafts were correlated. The rare instances of secondary procedures, such as tenolysis or scar correction, were used for biopsies of the muscle graft. Free neurovascular LD flaps were examined after a regeneration period between 2 and 6 years. The grafted LD was compared to normal, healthy LD muscle. Normal LD muscle showed a typical homogeneous pattern of types 1 and 2 fibers in a ratio of almost 1:1. No significant differences concerning fiber distribution and fiber diameters in three anatomic areas of the LD (proximal, medial, caudal) could be detected. After regeneration, the authors found the following: type grouping of muscle fiber types, fiber splitting, and groups of hypertrophic and atrophic fibers. Most of the muscle fibers were not reinnervated by axons and were atrophic or degenerated. The essential proliferation of connective and fatty tissue was absent. Normal and hypertrophic fibers were found mainly in the muscle grafts with good clinical results. In muscle grafts with good contraction force (M4), 46 percent of reinnervated muscle fibers were found; M3 contractility was correlated with 31 percent of reinnervated muscle fibers; M2 with 24 percent; and M1 with 21 percent of reinnervated fibers. The force of a free muscle graft seems to depend mainly on the quality of nerve regeneration. Characteristics of the muscle fiber itself were not examined extensively, because the single-fiber contractility of the regenerated fibers was similar to the contractility of normal, healthy fibers.

A continuous quality improvement approach to IL-372 documentation compliance in an academic emergency department, and its impact on dictation costs, billing practices, and average patient length of stay

OBJECTIVE

To determine whether continuous quality improvement (CQI) methodology could improve and maintain IL-372 documentation compliance in an academic emergency department (ED). The impact on transcription costs, billing practices, and average patient length of stay was also analyzed.

METHODS

Baseline IL-372 compliance data were collected and shared with staff during a multidisciplinary educational session. Faculty dictation became mandatory. Pocket-sized dictation templates were provided. A Documentation Improvement Committee monitored outcomes. Each month of the study period, a compliance officer reviewed approximately 100 records. The following indicators were monitored: IL-372 compliance rates, dictation rates, transcription costs, down-coding rates, percentage of billable records, and average patient length of stay. Individualized results were provided to faculty.

RESULTS

During the ten-month study period, compliance rates increased from 60% to 100% (p-trend < 0.001), while dictation rates increased from 69% to 100% (p < 0.001). Rates of down-coding adjustments improved from 54% to 2% (p-trend < 0.001). The percentage of billable records increased from 65% to 100% (p-trend < 0.001). Transcription costs increased a modest 16%. The average patient length of stay remained unchanged.

CONCLUSION

The application of CQI methodology, combined with the availability of dictation, resulted in sustained improvement in IL-372 compliance. This was associated with a parallel increase in dictation rates, although concurrent transcription costs increased only modestly. The percentage of billable records increased, while the number of charts requiring down-coding decreased, both beneficial outcomes. Average length of stay was not adversely impacted by this added documentation requirement.

[Surgical replantation]

In the early days of replantation surgery, if viability was restored the operation was judged a success. Nowadays restoration of viability alone is not sufficient to fulfill the criteria of successful replantation, which are as follows: Lack of severe systemic disturbances due to the replantation, a "functional extremity" according to the definition of Chen et al. (1978), no or little pain at the site of the replantation, good aesthetic results, and an acceptable length of time for rehabilitation and return to normal life. Successful replantation needs a therapy concept that is based on an exact definition of the amputation injury from the viewpoint of the amount of severance, the level of the amputation, and the type of amputation mechanism, complete knowledge of current replantation indications, and exact selection of patients amenable for replantation.

[Early microsurgical revision of the brachial plexus in traumatic birth injuries. Patient selection and outcome]

A review of the literature reveals that with conventional treatment alone or in combination with secondary muscle/tendon transfer, about 4-43% of cases show incomplete recovery with severe functional and/or aesthetic impairment (group III). If these patients undergo early microsurgical brachial plexus revision, regeneration without significant functional and/or aesthetic impairment (shift from group III to group II) can be achieved in 80-90% of cases. Moreover, microsurgical reconstruction of the brachial plexus increases the possibilities of secondary muscle/tendon transfers. Therefore, provided patient selection is good, severe obstetrical brachial plexus injuries should be scheduled for early microsurgical revision. There is no need to wait for a frustrating spontaneous recovery. Our concept is based on our experience with more than 1100 patients presenting with brachial plexus lesions between 1981 and 1996 and treated in our institution. There were 217 obstetrical brachial plexus lesions, 133 of which were treated conservatively. In 84 cases operative treatment was necessary. Fifty-one cases underwent early revision of the brachial plexus, and secondary tendon transfer was done in 33 patients.

[Secondary replacement operations for reconstruction of elbow joint function after lesion of the brachial plexus]

Elbow flexion plays a key role in the overall function of the upper extremity. In the case of unilateral complete brachial plexus lesion, restoration of elbow flexion will dramatically increase the patient's chances of regaining bimanual prehension. Furthermore, depending on the type of reconstruction, stability of the glenohumeral joint as well as some supination function of the forearm can be restored to a varying degree at the same time. Depending on the level of brachial plexus lesion and/or reinnervation, different reconstructive procedures are available. In order to select the best treatment option for the patient it is necessary to known the extent of the lesion of the brachial plexus and/or ventral upper arm muscles, to time the operation appropriately, to be aware of all treatment possibilities and to recall the special problems of tendon transfer for brachial plexus patients. Our concept is based on our experience with more than 1100 patients presenting a brachial plexus lesion between 1981 and 1996 and treated in our institution. There were 528 operative revisions of the brachial plexus. Some 225 patients underwent secondary muscle/tendon transfers. In 35 patients elbow flexion was reconstructed by bipolar latissimus dorsi transfer (n = 10), triceps-to-biceps transfer (n = 15), modified flexor/pronator muscle mass proximalization (n = 6) and the multiple-stage free functional muscle transfer after intercostal nerve transfer (n = 4).

Skin and bones: dermatologic conditions with skeletal abnormalities

OBJECTIVE

Radiologists should be aware of the fact that many dermatologic conditions have associated skeletal abnormalities. This pictorial essay seeks to acquaint radiologists with these associations.

DESIGN

Twenty-four skin and bone conditions are portrayed and discussed under the headings of: disorders of the epidermis, disorders of the dermis, disorders of the sebaceous glands, disorders of pigmentation, disorders of the nails, tumors, the phakomatoses, immunologic-allergic disorders, and infections. In addition, a table is provided as an expanded listing of conditions with such associations.

CONCLUSION

This pictorial essay will help radiologists and other practitioners become familiar with dermatologic conditions that have associated skeletal abnormalities.

[Time limited immunosuppression in allogenic nerve transplant in the rat]

A rejection response of peripheral nerve allografts eliminates the Schwann cells without destroying the tubular architecture and leads to a regeneration of inferior quality. Under immunosuppression this rejection is prevented, and allogenic Schwann cells persist in the grafts, leading to a better regeneration result. In adult rats of the strains DA and LEW.1W, a 2,5 cm segment of the sciatic nerve was grafted. Under Cyclosporin A regeneration was allowed to take place for 12 weeks. Thereafter, immunosuppression was discontinued in one group and gradually reduced in another. Regeneration quality was compared after an additional six weeks in comparison to an autologous control. Best regeneration was observed in the autologous control; no statistical differences were observed between the two experimental groups. Gradual reduction of immunosuppression did not result in an atraumatic replacement of donor derived Schwann cells by recipient derived ones. Allogenic nerve grafting needs continuous immunosuppression, which to date precludes it from clinical application.

[Timing of free microsurgical tissue transplantation in hand injuries during the acute phase]

Due to favourable survival rates in replantation surgery and a high standard of free tissue transplantation, the interval between injury and microsurgical reconstruction has continuously decreased in the past. The acute phase can be defined as the interval ranging from emergency procedures within 24 hours to "urgence différée" procedures within 72 hours. Bearing in mind the infection rates of 1.5% and 17.5% respectively as it has been reported in the literature, we should encourage emergency reconstructions. However, in most cases of upper extremity injuries, reconstruction with conventional flaps is possible. Between 1981 and 1991, 674 free tissue transplantation have been performed in our unit, 61% of the cases of free tissue transplantations to the upper extremity were done in the acute phase, the majority within 72 hours (urgence différée). No significant differences in rates of infections were evident comparing acute phase and urgence différée procedures. Because of this, we still support the concept of urgence différée. In our opinion the following advantages have to be considered: urgence différée allows a second loop operation, the vitality of the extremity can be ascertained, and the reconstructive procedure can be planned more precisely. Last not least, a procedure performed during the day-time assures better operating conditions. This concept is demonstrated with clinical cases.

[Muscle-specific changes in free latissimus dorsi transplantation in the rat model]

The aim of this study is to gain further knowledge concerning the regeneration of reinnervated, freely transplanted muscles. Therefore, we used a rat model, consisting of eight rats per group, in which the latissimus dorsi muscle was transplanted orthotopically, after a period of time of two and twelve weeks harvested, then evaluated histologically and enzyme-histochemically. As controls we used a group of non-operated muscles. At date of removal, the patency of the vascular anastomoses was checked clinically and histologically. Additionally, electrophysiological measurements and conventional and enzyme-histochemical histologies were performed. Two weeks after the free neurovascular flap transplantation, the muscle was not innervated yet, histologically a dissolved pattern of type 1 and type 2 muscle fibers was found. After twelve weeks of time, the muscles were reinnervated again, muscle contraction was positive after electrical stimulation and the typical pattern of fibers was reestablished.

[Functional and esthetic assessment of donor site defects following transfer of the gracilis muscle]

In order to determine donor-site morbidity after elevation of the gracilis flap, 53 patients from four different departments were examined. The patients filled out a questionnaire about their complaints. 36 patients underwent dynamometric measurements. The adduction strength of the hip-joint was decreased by 11% after elevation of the gracilis muscle. This decrease in strength was not noticed by the patients. 53% of the patients complained about hypesthesia or dysesthesia corresponding to the cutaneous territory of the obturator nerve. The contour of the thigh was adversely affected after elevation of a musculocutaneous flap. The gracilis flap has a low but definite donor-site morbidity, especially concerning the esthetic aspect.

Morphometric changes in free neurovascular latissimus dorsi flaps: an experimental study

This study was designed to investigate regeneration of reinnervated, free transplanted muscles. We used a rat model, consisting of eight rats per group, in which the latissimus dorsi muscle was transplanted orthotopically and then harvested and evaluated after 2 and 12 weeks. Age-matched control animals were used to oppose non-operated muscles. At date of removal the patency of the vascular anastomoses was checked clinically and histologically. Electrophysiological measurements were also performed and conventional and enzyme histochemical histological slides manufactured. Two weeks after the free neurovascular flap transfer the muscle was not yet innervated, and histologically a dissolved pattern of type 1 and type IIA muscle fibres was found. The muscle fibres demonstrated a decrease of more than 50% cross-sectional area. After 12 weeks the muscles were reinnervated again; muscle contraction was positive with electrical stimulation and the cross-sectional area had regained 80% of the activity of normal muscle fibres. With enzyme histochemical staining the typical type grouping of reinnervated muscles could be demonstrated.

Brachial plexus surgery: our concept of the last twelve years

In patients with brachial plexus injuries restoration of complete function is seldom seen. The diagnosis is a clinical one; investigations such as MRI or myelography are not sufficiently reliable to base surgical indications on them. Surgery has to be performed within the first six months after the trauma. The surgical procedure firstly includes an exact intraoperative definition of the extent of the lesion. Depending on the type of the lesion, microsurgical neurolysis, nerve grafting, or reneurotization is performed. When regeneration is complete, secondary operations may follow if necessary as part of our integrated concept. The spectrum of secondary operations in our patients includes arthrodesis, tenodesis, tendon transfers, muscle transfers, and free neurovascular tissue transfer. In selected cases with extensive lesions a bifunctional latissimus dorsi transfer allows restoration of minimal grip with simultaneous elbow flexion. Our concept includes a series of hierarchical steps: 1. Diagnosis and indication 2. Nerve repair 3. Intensive physiotherapy, control in intervals 4. Secondary operations--if necessary 5. Intensive physiotherapy 6. Ergotherapy, orthosis In the last 12 years 362 patients with brachial plexus lesions have been operated on in our clinic. In these patients we performed 104 neurolyses, 126 nerve grafting procedures, 87 reneurotizations, and 191 secondary operations in 96 patients. Only the combination of nerve repair with both conventional and newer methods of tendon and muscle transfers can restore the maximum function for the individual situation.

[Pulley for strengthening a muscle replacement operation across two joints in brachial plexus lesion: description of the surgical technique]

The reconstruction of lost muscle functions in cases of brachial plexus lesion is possible even in those cases where primary nerve reconstruction was not performed or unsuccessful. If there are only few motor nerves available, we prefer free latissimus dorsi transplantation or pedicled latissimus dorsi transposition for replacement of biceps and finger flexors. The combination of elbow flexion and finger flexion becomes possible when the transposed motor is passed around a suitable pulley in the elbow region like the flexor carpi ulnaris or carpi radialis.

New antiserum against Ki-67 antigen suitable for double immunostaining of paraffin wax sections

AIMS

To prepare a rabbit antiserum equivalent to MIB 1 to permit the simultaneous assessment of cell proliferation and other markers of interest using double labelling studies.

METHODS

Rabbits were immunised with a synthetic peptide deduced from the cDNA sequence coding for the Ki-67 antigen. Serum samples were tested for immunoreactivity using different immunobiochemical methods.

RESULTS

A polyclonal antiserum was derived which detects the native as well as recombinant parts of the Ki-67 antigen in different test systems. Furthermore, the antiserum stains the Ki-67 antigen in routinely processed, paraffin wax embedded material.

CONCLUSIONS

After antigen unmasking by microwave treatment the antiserum described here represents a powerful tool for the determination of growth fractions even in archival material. It is especially suitable for double staining experiments in combination with monoclonal antibodies.

The cell proliferation-associated antigen of antibody Ki-67: a very large, ubiquitous nuclear protein with numerous repeated elements, representing a new kind of cell cycle-maintaining proteins

The antigen defined by mAb Ki-67 is a human nuclear protein the expression of which is strictly associated with cell proliferation and which is widely used in routine pathology as a "proliferation marker" to measure the growth fraction of cells in human tumors. Ki-67 detects a double band with apparent molecular weights of 395 and 345 kD in immunoblots of proteins from proliferating cells. We cloned and sequenced the full length cDNA, identified two differentially spliced isoforms of mRNA with open reading frames of 9,768 and 8,688 bp encoding for this cell proliferation-associated protein with calculated molecular weights of 358,761 D and 319,508 D, respectively. New mAbs against a bacterially expressed part and a synthetic polypeptide deduced from the isolated cDNA react with the native Ki-67 antigen, thus providing a circle of evidence that we have cloned the authentic Ki-67 antigen cDNA. The central part of the Ki-67 antigen cDNA contains a large 6,845-bp exon with 16 tandemly repeated 366-bp elements, the "Ki-67 repeats", each including a highly conserved new motif of 66 bp, the "Ki-67 motif", which encodes for the epitope detected by Ki-67. Computer analysis of the nucleic acid and the deduced amino acid sequence of the Ki-67 antigen confirmed that the cDNA encodes for a nuclear and short-lived protein without any significant homology to known sequences. Ki-67 antigen-specific antisense oligonucleotides inhibit the proliferation of IM-9 cell line cells, indicating that the Ki-67 antigen may be an absolute requirement for maintaining cell proliferation. We conclude that the Ki-67 antigen defines a new category of cell cycle-associated nuclear nonhistone proteins.

Antigen unmasking on formalin-fixed, paraffin-embedded tissue sections

Enzymatic and non-enzymatic treatments for antigen unmasking on formalin-fixed, paraffin-embedded, dewaxed sections were optimized and compared by the use of a panel of antibodies of diagnostic relevance (anti-cytokeratins, vimentin, S-100, T- and B-cell receptors, Ki-67/MIB 1, muscle actin). Non-enzymatic unmasking was obtained by boiling the slides in a microwave oven in 0.01 M salt solution (pH 6) or in 6 M urea. Trypsin or pronase digestion was used for comparison and found to be necessary for some of the reagents. The investigation was then extended to 256 antibodies; the epitopic amino acid sequence was known for 48 of them. We found that enzymatic and non-enzymatic antigen unmasking are not dependent on the epitope sequence, but some antigens benefit selectively from one treatment but not from the other. Denaturation of proteins is the likely mechanism which leads to immunodetection on microwave oven-boiled slides; this suggestion is supported by the use of denaturating solutions and by the observation that endogenous enzymes were inactivated and a few antigens were no longer immunodetectable after boiling. Non-enzymatic methods for antigen unmasking are a powerful new tool for broadening the use of antibodies for immunostaining formalin-fixed, paraffin-embedded sections and should be used in parallel with the traditional enzymatic methods.

Understanding young children's health beliefs and diabetes regimen adherence

Previous studies of chronic illness management in children have focused mainly on parents' health beliefs. However, children's health beliefs also can be an important factor in predicting adherence. Indeed, children 6 to 10 years old spend most waking hours away from home, are under less parental supervision, and are becoming more responsible for their own care. The purpose of this study was to develop a pictorial, multi-item instrument to measure dimensions of the Health Belief Model (HBM) and self-efficacy (SE), designed specifically for children with diabetes, thus making it possible to examine both the parent's and child's health beliefs; to explore the relationship between their beliefs; and to examine the extent to which these beliefs are predictors of adherence and metabolic control.

New Ki-67-equivalent murine monoclonal antibodies (MIB 1-3) generated against bacterially expressed parts of the Ki-67 cDNA containing three 62 base pair repetitive elements encoding for the Ki-67 epitope

BACKGROUND

The monoclonal antibody Ki-67 reacts with a human nuclear cell proliferation-associated antigen that is expressed in all cells that are not in G0. Recently, we could demonstrate that Ki-67 detects a double band in Western blots of proliferating cells with apparent molecular weights of 345 kilodaltons and 395 kilodaltons, respectively. Furthermore, initial molecular biologic data favored the view that the epitope detected by Ki-67 might be encoded by a repetitive 66 bp element.

EXPERIMENTAL DESIGN

In order to verify this assumption, parts of the Ki-67 cDNA were bacterially expressed, and the fusion proteins obtained were used to elicit new monoclonal antibodies. The specificities of the new reagents were tested by immunohistochemistry, Western blot, and enzyme-linked immunosorbent assay techniques.

RESULTS

The somatic cell fusions revealed a number of antibodies with immunoreactivities comparable to Ki-67. Three antibodies, designated MIB 1-3, were further characterized. Besides the fact that their immunostaining reactivity is identical with that of Ki-67, all new antibodies react in Western blots with native Ki-67 antigen. Furthermore, Western blot and competitive binding assays by enzyme-linked immunosorbent assay clearly demonstrate that MIB 1 and MIB 3, like the original Ki-67 antibody, react with an epitope that is encoded by the 66 bp repetitive element mentioned above. MIB 2, however, reacts with an epitope distinct from this latter structure. In addition, after antigen unmasking by microwave treatment, MIB 1 and MIB 3 detect the Ki-67 antigen in paraffin sections.

CONCLUSIONS

Our results demonstrate that it is possible to use bacterially expressed parts of the Ki-67 antigen as immunogen to elicit antibodies that react with the native antigen. While MIB 1 and MIB 3 detect the same or a very similar epitope as the original antibody Ki-67, MIB 2 clearly differs in its fine specificity. Our results provide a circle of evidence that the cDNA sequence thus far determined encodes for the Ki-67 antigen. Furthermore, the new antibodies may become powerful tools for routine histopathology and for further functional characterization of the Ki-67 antigen.

Enzymhistochemical evaluation of ulnar nerve grafts in brachial plexus lesions

Our concept for the reconstruction of brachial plexus injuries includes an intercostal nerve transfer to the vascularized ulnar nerve graft. A free neurovascular latissimus dorsi is then transferred in a second stage operation. For optimization of the regeneration result, the operative planning of the second step includes nerve biopsies and enzymhistochemical evaluation for the distribution of motor axons. The staining method according to Scabolcz et al. is described and clinical cases are presented.

Immunobiochemical characterization of the antigen detected by monoclonal antibody IND.64. Evidence that IND.64 reacts with the cell proliferation associated nuclear antigen previously defined by Ki-67

The immunohistochemical characteristics of the monoclonal antibody IND.64 are very similar to those of the monoclonal antibody Ki-67. The aim of this study was to further characterize this new antibody and to compare it with Ki-67 using immunobiochemical methods. Our results demonstrate that the similarity between the antibodies holds true even at the molecular level. Immunoblot analysis of IM-9-cell lysates with both antibodies showed a double band with apparent molecular weights of 395 kD and 345 kD, respectively. Competition ELISAs using a synthetic peptide derived from the thus far determined Ki-67 cDNA sequence as competitor, indicate that IND.64 may recognize the same epitope as Ki-67. The IND.64 epitope resides at least within a 20 amino acid sequence which also contains the Ki-67 epitope. Since IND.64 is of the IgG2b subclass, while Ki-67 is of the IgG1 subclass, the two antibodies may be useful for double immunostaining. In addition, IND.64 may help in determining the still unknown function of the antigen it recognizes.

Monoclonal antibodies against recombinant parts of the Ki-67 antigen (MIB 1 and MIB 3) detect proliferating cells in microwave-processed formalin-fixed paraffin sections

The monoclonal antibody Ki-67 reacts with a human nuclear cell proliferation-associated antigen that is expressed in all active parts of the cell cycle. Recently we have raised monoclonal antibodies, MIB 1-3, against recombinant parts of the Ki-67 antigen. These antibodies are true Ki-67 equivalents, as demonstrated by immunostaining of fresh specimens, biochemistry, and molecular biological techniques. Formalin-fixed, paraffin-embedded sections routinely processed for immunohistochemistry failed to stain for Ki-67 and MIB 2. Antibodies MIB 1 and MIB 3 labelled mitotic figures, while non-mitotic proliferating cells were negative under these conditions. However, when dewaxed microwave oven-processed paraffin sections of formalin-fixed tissues were used, MIB 1 and MIB 3 gave strong nuclear staining of those cells presumed to proliferate under a variety of normal and neoplastic conditions. Moreover, routine decalcification or depigmentation techniques did not alter the immunoreactivity of MIB 1 and MIB 3 with microwave-processed paraffin sections. This method is highly reproducible, easy to perform at low cost, and no additional technical skill is needed because after microwave treatment just routine immunohistochemical methods are used. Since we have successfully applied this new method to sections obtained from paraffin blocks stored for a long time (in one case more than 60 years), the assessment of cell kinetics through the detection of Ki-67 antigen is now possible on archival material collected in histopathology departments all over the world.

Monoclonal antibody JC1: new reagent for studying cell proliferation

AIM

To characterise a newly developed mouse monoclonal antibody JC1 which recognises a nuclear antigen present in proliferating cells in normal tissues and neoplastic lesions, and which is absent in resting cells.

METHODS

The methodology was established using a representative range of frozen sections from normal tissues and from certain tumours which were immunostained with antibodies Ki67 and JC1. The molecular weight of the antigen recognised by JC1 was obtained by western blot analysis and this was compared with that of Ki67. IM-9 cell lysates containing Ki67 derived plasmids were also tested with JC1 antibody.

RESULTS

Biochemical investigation indicated that the antigen recognised by JC1 gives two molecular weight bands of 212 and 123 kilodaltons, which is distinct from the well characterised anti-proliferation monoclonal antibody Ki67 (395-345 kilodaltons). In addition recombinant Ki67 protein is not recognised by JC1. Immunohistological reactivity was seen in areas known to contain numerous proliferating cells such as lymphoid germinal centres, splenic white matter, cortical thymocytes and undifferentiated spermatogonia. In tumours many cells from adenocarcinomas, oat cell carcinomas, squamous cell carcinomas of lung, and seminomas were labelled by JC1 with a distribution and proportion similar to that seen with Ki67. In normal tissues the only apparent difference was in testis where JC1 stained a considerably greater number of cells than Ki67. In all cases studied the new antibody showed nuclear reactivity only. JC1 did not show any cytoplasmic crossreactivity with squamous cells as is frequently seen with Ki67.

CONCLUSION

Antibody JC1, which recognises a nuclear antigen present in proliferating cells, should provide a useful adjunct to Ki67 as a marker of proliferation especially in those cases such as squamous cell carcinomas where a Ki67 index cannot be determined.

Impact of self-management education on the functional health status of older adults with heart disease

This paper presents findings from the evaluation of a self-management education program based on self-regulation principles. Older men and women (N = 324) were randomly assigned to program and control groups. Outcomes were measured using the Sickness Impact Profile. Twelve months following baseline data collection, psychosocial functioning of program participants was significantly better than that of controls. Different program effects were noted when results were analyzed by participant gender.

Noncompliance with Universal Precautions Policy: why do physicians and nurses recap needles?

In 1987 the Centers for Disease Control published a Universal Precautions Policy establishing blood and body fluid procedures to be used consistently with all patients. An important and unequivocal Universal Precautions Policy recommendation with regard to avoidance of needlestick injuries is that needles should never be recapped. We examined the recapping-related attitudes and behaviors of physicians and nurses at four large teaching hospitals with patients with acquired immunodeficiency syndrome and with Universal Precautions Policy in-service training programs. Compliance was found to be considerably less than optimal. According to unannounced needle counts in disposal boxes, the percentage of recapped needles was always greater than 25% and exceeded 50% in four instances. Recapping was related to inadequate knowledge, concerns about personal risk, forgetfulness, being "too busy" to follow the Universal Precautions Policy, and the misperception that recapping is a way to avoid needlestick injury. Strategies are suggested to improve and supplement traditional in-service education.

Determinants of breast self-examination after a benign biopsy

Although breast self-examination (BSE) continues to be recommended as an adjunct to clinical screening techniques for the early detection of breast cancer, little is known about events that might negatively influence long-term adherence. The primary aim of this investigation was to determine if regularity of BSE would decline after a benign breast biopsy. Analyses are based on 655 women: 83 women who self-discovered the breast problem by BSE, 179 women in whom the problem was discovered by the health care system, and a control group of 393 women who had no history of breast problems. Frequency of BSE was assessed over two six-month periods and collapsed into three categories--nonpractitioner, irregular practitioner, and regular practitioner. Results indicated that the percentage of women in the self-discovered group who reported decreased regularity of BSE was over three times higher than that found in the control group. The largest percentage increase in BSE frequency was evidenced by the health care-discovered group. Logistic regressions revealed that the biopsy experience was a more powerful indicator of subsequent BSE practice than either sociodemographic characteristics or whether one engaged in other preventive health behaviors. The data provide substantial evidence that a benign biopsy can affect BSE practice, with the direction and magnitude of the change influenced by mode of discovery of the breast problem, perceived degree of confidence in ability to perform BSE, and level of practice before the biopsy. Postbiopsy educational strategies incorporating these findings and targeted at specific subgroups are outlined.

Recruitment of a large community of pediatricians in a collaborative research project

To investigate the effects of an educational program on the compliance-enhancing behavior of pediatricians and the subsequent regimen adherence of their patients, it was necessary to enlist the participation of a large number of pediatric practitioners. The physicians had to be motivated to attend two evenings of tutorial training; to enroll their patients in the project; and to complete detailed study documents. Ultimately, 90 of the 97 pediatricians practicing in the community took part. The following factors are felt to have contributed to the widespread participation of the pediatricians: 1) the subject was interesting and of relevance to clinical practice; 2) the study was designed so as not to interfere with office routine; 3) major demands were not made on the patients; 4) due consideration was given to the value of the physicians' participation; and 5) communication between the investigators and the practitioners was facilitated by a liaison pediatrician.

Improving pediatricians' compliance-enhancing practices. A randomized trial

Previous evaluations of continuing medical education (CME) have yielded conflicting results regarding its effects on physician knowledge, performance, and subsequent patient outcomes. Poor adherence by mothers to prescribed pediatric regimens is a separate, but well-documented, problem. In the present study we assessed the ability of CME to: (1) increase the knowledge of pediatricians about compliance-enhancing strategies; (2) increase the performance of these practices by pediatricians; and (3) improve mothers' compliance with antibiotic regimens for their children's otitis media. Ninety pediatricians were randomly assigned to either a control group or one of two CME interventions: tutorial plus printed materials or mailed printed materials only. Following the interventions, data on compliance and on reported behaviors of pediatricians were gathered from a random sample of mothers (N = 771) whose children were being treated for otitis media. Findings indicated that CME increased physician knowledge and compliance-enhancing practices and resulted in improvement in mothers' adherence to therapy.

Perceptions held by obese children and their parents: implications for weight control intervention

The study was designed to identify some of the psychosocial barriers to compliance in a hospital-based weight control intervention program for adolescents. Forty obese adolescents, 10 to 16 years of age, and their parents were surveyed prior to participation in a behavioral change weight control program at a major teaching hospital. Significant correlations were obtained between weight loss outcome and six factors. In obese adolescents, weight loss was significantly associated with their beliefs regarding: (1) personal control over weight, (2) barriers or difficulty of losing weight, (3) medical problems as a cause of their obesity, (4) family problems as a cause of their obesity, and (5) perceived willingness of family members to diet. It is suggested that greater weight loss in children who perceived more barriers/difficulty and less family willingness to diet may reflect the importance of having realistic expectations related to behavioral compliance. In addition, a positive parental attitude or expectation that the child was less likely to be overweight in the future was associated with greater weight loss compliance. Other parental health beliefs, however, did not generally predict the child's weight loss response to the intervention. The findings lend support to the significance of the adolescent's beliefs regarding weight and family support in explaining weight loss response to a behavioral change intervention program.

Social learning theory and the Health Belief Model

The Health Belief Model, social learning theory (recently relabelled social cognitive theory), self-efficacy, and locus of control have all been applied with varying success to problems of explaining, predicting, and influencing behavior. Yet, there is conceptual confusion among researchers and practitioners about the interrelationships of these theories and variables. This article attempts to show how these explanatory factors may be related, and in so doing, posits a revised explanatory model which incorporates self-efficacy into the Health Belief Model. Specifically, self-efficacy is proposed as a separate independent variable along with the traditional health belief variables of perceived susceptibility, severity, benefits, and barriers. Incentive to behave (health motivation) is also a component of the model. Locus of control is not included explicitly because it is believed to be incorporated within other elements of the model. It is predicted that the new formulation will more fully account for health-related behavior than did earlier formulations, and will suggest more effective behavioral interventions than have hitherto been available to health educators.

AIDS and behavioral change to reduce risk: a review

Published reports describing behavioral changes in response to the threat of AIDS (acquired immunodeficiency syndrome) are reviewed. These studies demonstrate rapid, profound, but expectably incomplete alterations in the behavior of both homosexual/bisexual males and intravenous drug users. This is true in the highest risk metropolitan areas such as New York City and in areas with lower AIDS incidence. Risk reduction is occurring more frequently through the modification of sexual or drug-use behavior than through its elimination. In contrast to aggregate data, longitudinal descriptions of individual behavior demonstrate considerable instability or recidivism. Behavioral change in the potentially vulnerable heterosexual adolescent and young adult populations is less common, as is risk reduction among urban minorities. Reports of AIDS-related knowledge and attitudes generally parallel the pattern of behavioral changes. Nonetheless, few studies investigate the relationship of knowledge and attitudes to risk reduction. Future studies should provide much-needed information about the determinants as well as the magnitude of behavioral changes required to reduce the further spread of AIDS.

Behavioral science perspectives on health hazard/health risk appraisal

Health-promotion efforts often employ HRA as a device for providing an individual with quantitative information about the consequences of personal health-related behaviors and as an attempt to motivate the client to adopt recommendations directed at establishing a healthier lifestyle. From a behavioral science perspective, the HRA approach and process contain elements that (at least in retrospective analysis) appear to be founded in relevant bodies of theory. First, HRA seems to be a reasonably efficient mechanism for transmitting information relative to associations between personal health behaviors and mortality risks. Moreover, while general knowledge and advice about the untoward consequences of risk factors (such as smoking, obesity, high blood pressure, etc.) are currently widespread, HRA provides new and specific information: the client's own relative risks. Some individuals who voluntarily participate in HRA bring to the experience an already high level of readiness to take action; for them, the technique may constitute the final necessary stimulus or "cue to action" [12]. Referring to a "borrowing from the future" phenomenon, Green points out that "some educational efforts are really only triggers to behavior that would have changed eventually anyway" [44, p. 159]. Thus, where motivation is sufficiently high, receipt of HRA feedback information may by itself be capable of inducing behavior change. Second, the focus on awareness and personalization of mortality risk fits well with most theoretical formulations concerning attitudes and beliefs involved in health-related decision making. Although the emphasis on mortality and often distant negative outcomes is problematic, increasing the client's perception of personal vulnerability is a psychologically defensible approach, and fear arousal can generate attitude change (although questions of appropriate level, duration of effects obtained, acceptability, etc. still need to be resolved). Third, HRA might be expected to enhance the client's perception of the benefits associated with lifestyle modifications and may even increase personal belief in his or her ability to undertake such changes in behavior. However, in light of the fact that the behaviors to be altered are complex, usually well-established and repetitive, and require different skills to extinguish, the provision of typical HRA feedback should not (on a theoretical basis) ordinarily be expected to accomplish much beyond information transmission, belief or attitude change, and the induction of some level of motivation.(ABSTRACT TRUNCATED AT 400 WORDS)

Evaluation of a minimal-contact smoking cessation intervention in an outpatient setting

We examined the ability of a provider-initiated, minimal-contact intervention to modify the smoking behavior of ambulatory clinic patients. Smokers at two outpatient sites were assigned to one of three groups: provider intervention only (PI); provider intervention plus self-help manual (PI/M); and usual care (control) group (C). The physician message emphasized the patient's personal susceptibility, the physician's concern, and the patient's ability to quit (self-efficacy). The nurse consultation concentrated on benefits and barriers associated with stopping, and on strategies for cessation. Telephone interviews were conducted with the 250 participants within a few days of their clinic visit and again at one and six months. Both PI and PI/M proved to be superior to usual care in motivating attempts to quit at both one-month and six-month follow-ups, and logistic regression analyses indicated that participants receiving the self-help manual in addition to the health provider message were between two and three times more likely to quit smoking during the study period than were participants in either of the other study groups.

The doctor-patient relationship and counseling for preventive care

Theories and research related to the doctor-patient relationship have developed in a context of therapeutic care. This context is an increasingly inadequate definition of the boundaries of the doctor-patient relationship, as expectations grow for the physician's role in counseling for disease prevention and health promotion. This paper reviews the literature of the doctor-patient relationship, and extends its application to this newer context. Suggestions are discussed for overcoming some of the obstacles to the successful incorporation of counseling for preventive care in daily medical practice. Doctors and patients will benefit from a clarified understanding of their counseling responsibilities in disease prevention and health promotion as the theoretical and practical complexities of providing health care in medical institutions are examined.

Congenital bilateral absence of the fifth ray and vaginal atresia

We have studied an infant with respiratory distress, absent fifth rays of the hands, and hydrometrocolpos. Congenital absence of the fifth ray of the hand is a rare malformation. In some syndromes the ulnar defects are symmetrical; however, as an isolated anomaly the defects are usually asymmetric. This patient's malformations appear to be unique in that the ulnar ray was affected bilaterally, with an associated genital malformation.

Beliefs about control of smoking and smoking behavior: a comparison of different measures in different groups

This study investigated several measures of beliefs about controlling smoking as predictors of cessation and reduction at one and six months after a medically-based control program. Smokers (n = 250 total) attending general medicine clinics at University and Veterans Administration facilities received advice to quit from both physicians and nurses. Beliefs about difficulty resisting urges to smoke in 15 situations, their frequency of occurrence, and general level of difficulty were assessed at baseline. For the University group of patients, significant relationships were found between both general and specific indexes and both cessation and reduction at one month. Although a greater change in smoking was seen at six months, few belief measures remained predictive. At one month, global measures were as useful as specific ones, although difficulty in situations of negative emotion was a consistent and strong predictor. Marked differences between the two sites were found; virtually no measure of difficulty proved predictive for the VA group.

Patient medication instruction and provider interactions: effects on knowledge and attitudes

This prospective study examines whether a patient medication instruction sheet (PMI) given to clinic patients by their health care provider affects knowledge and/or attitudes with thiazide diuretic use as part of an antihypertensive regimen. Adult male patients (N = 285) in a general medicine clinic were assigned to groups receiving the American Medical Association PMI describing their diuretic. Patients getting the PMI obtained it either directly from their provider or at the pharmacy dispensing window. All patients were surveyed by phone 1 week following the clinic visit with regard to the PMI, knowledge of medication use, and attitudes toward drug use. Results indicate that a provider-dispensed PMI results in higher levels of drug knowledge and greater patient satisfaction with their knowledge than a pharmacy-dispensed PMI. In addition, the PMIs educational value may be lessened by an incomplete verbal consult. This study demonstrates that the AMA PMI is an effective educational tool when distributed by a provider and can promote better understanding and use of prescribed medications.

The role of self-efficacy in achieving health behavior change

The concept of self-efficacy is receiving increasing recognition as a predictor of health behavior change and maintenance. The purpose of this article is to facilitate a clearer understanding of both the concept and its relevance for health education research and practice. Self-efficacy is first defined and distinguished from other related concepts. Next, studies of the self-efficacy concept as it relates to health practices are examined. This review focuses on cigarette smoking, weight control, contraception, alcohol abuse and exercise behaviors. The studies reviewed suggest strong relationships between self-efficacy and health behavior change and maintenance. Experimental manipulations of self-efficacy suggest that efficacy can be enhanced and that this enhancement is related to subsequent health behavior change. The findings from these studies also suggest methods for modifying health practices. These methods diverge from many of the current, traditional methods for changing health practices. Recommendations for incorporating the enhancement of self-efficacy into health behavior change programs are made in light of the reviewed findings.

Correlates of mothers' use of medications for their children

This study examines the extent, determinants and quality of mothers' independent use of medications for treating their children's symptoms. Data on mother-initiated medication behavior (MIMB) were obtained from a stratified systematic random sample of 500 mothers of children presenting for a well child visit at two pediatric ambulatory care sites. Six expert pediatric judges each rated every reported medication use (N = 3908) along three dimensions (usefulness, correctness and harmfulness or helpfulness) and also evaluated the overall appropriateness of each mother's MIMB. Results indicate that: (1) mothers keep available and use for children a considerable variety of different medications and medical applicances; (2) a positive linear relationship exists between mothers' socioeconomic status (SES) and degree of MIMB; (3) mothers' attitudes toward medications and toward their children's health are associated with the number of categories of medications and applicances they possess and use; (4) the combination of SES and attitudinal characteristics accounts for substantial portions of the variance in MIMB; and (5) judges' ratings show only minimal-level support of MIMB (extending to mothers in all SES groups) and are linearly related to SES (P less than 0.001). These findings emphasize the need for health care providers to review MIMB, and to provide advice concerning use and misuse of mother-initiated treatments.

The syndrome of achalasia of the esophagus, ACTH insensitivity and alacrima

A 7-year-old male presented with a triple A syndrome, a tirad of ACTH insensitivity, achilasia and alacrima. His clinical course is followed and the literature reviewed.